Provider Demographics
NPI:1992129621
Name:ROBITAILLE, BLAKE (PHARMD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:ROBITAILLE
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 1:1277 M 89
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-1919
Mailing Address - Country:US
Mailing Address - Phone:269-685-5623
Mailing Address - Fax:269-685-5814
Practice Address - Street 1:1277 M 89
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1919
Practice Address - Country:US
Practice Address - Phone:269-685-5623
Practice Address - Fax:269-685-5814
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-17
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039327183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist