Provider Demographics
NPI:1962729566
Name:BLAIR, KALEB WADE (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:KALEB
Middle Name:WADE
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PHARMD, RPH
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 250
Mailing Address - Street 2:
Mailing Address - City:ISOM
Mailing Address - State:KY
Mailing Address - Zip Code:41824-0250
Mailing Address - Country:US
Mailing Address - Phone:606-633-9238
Mailing Address - Fax:606-633-0222
Practice Address - Street 1:93 ISOM PLAZA
Practice Address - Street 2:
Practice Address - City:ISOM
Practice Address - State:KY
Practice Address - Zip Code:41824
Practice Address - Country:US
Practice Address - Phone:606-633-9238
Practice Address - Fax:606-633-0222
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY014012183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist