Provider Demographics
NPI:1063695641
Name:BLASI, CARLA M (RPH)
Entity type:Individual
Prefix:MS
First Name:CARLA
Middle Name:M
Last Name:BLASI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 AVENUE T
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4911
Mailing Address - Country:US
Mailing Address - Phone:347-791-7283
Mailing Address - Fax:
Practice Address - Street 1:5027 NEW UTRECHT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3547
Practice Address - Country:US
Practice Address - Phone:718-431-8000
Practice Address - Fax:718-431-8943
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034640-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1750322657OtherNPI
NY02709626Medicaid