Provider Demographics
NPI:1063437184
Name:RICE, BLAKE
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:
Last Name:RICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 826
Mailing Address - Street 2:
Mailing Address - City:RIDDLE
Mailing Address - State:OR
Mailing Address - Zip Code:97469-0826
Mailing Address - Country:US
Mailing Address - Phone:541-874-2406
Mailing Address - Fax:541-874-3256
Practice Address - Street 1:142 MAIN STREET
Practice Address - Street 2:
Practice Address - City:RIDDLE
Practice Address - State:OR
Practice Address - Zip Code:97467
Practice Address - Country:US
Practice Address - Phone:541-874-2406
Practice Address - Fax:541-874-3256
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH0006533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR106254Medicare PIN
ORA11111Medicare UPIN