Provider Demographics
NPI:1215283593
Name:CROCKETT, BLAKE ADAM (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ADAM
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-5581
Mailing Address - Country:US
Mailing Address - Phone:417-206-3377
Mailing Address - Fax:
Practice Address - Street 1:3151 E 7TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-5581
Practice Address - Country:US
Practice Address - Phone:417-206-3377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012025394183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist