Provider Demographics
NPI:1912501958
Name:CORNWELL, BLAKE LORAN (PHARMD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:LORAN
Last Name:CORNWELL
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 1:1800 W MARIGOLD DR APT 7310
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7260
Mailing Address - Country:US
Mailing Address - Phone:309-241-8644
Mailing Address - Fax:
Practice Address - Street 1:6820 N PEARTREE LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2471
Practice Address - Country:US
Practice Address - Phone:309-241-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.302233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist