1497741144 NPI number — DR. CONRAD JAMES BLAKE PHARMD

Table of content: DR. CONRAD JAMES BLAKE PHARMD (NPI 1497741144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497741144 NPI number — DR. CONRAD JAMES BLAKE PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
CONRAD
Provider Middle Name:
JAMES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497741144
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 GROSMONT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARKS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89436-7047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-851-7788
Provider Business Mailing Address Fax Number:
775-851-7787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3515 AIRWAY DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89511-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-851-7788
Provider Business Practice Location Address Fax Number:
775-851-7788
Provider Enumeration Date:
09/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P1200X , with the licence number:  NV16076 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NV16076 . This is a "NV BOARD OF PHARMACY LIC" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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