Provider Demographics
NPI:1154919355
Name:BLAKE, CHARLES LEE (RPH)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:BLAKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1187 SOUTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-5582
Mailing Address - Country:US
Mailing Address - Phone:330-472-4072
Mailing Address - Fax:330-926-1474
Practice Address - Street 1:1187 SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-5582
Practice Address - Country:US
Practice Address - Phone:330-472-4072
Practice Address - Fax:330-926-1474
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03213285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03213285OtherSTATE OF OHIO BOARD OF PHARMACY