Provider Demographics
NPI:1538398128
Name:PERRY, BLANE EDWIN (RPH)
Entity type:Individual
Prefix:MR
First Name:BLANE
Middle Name:EDWIN
Last Name:PERRY
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 1:585 HERMAN SMITH RD
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4442
Mailing Address - Country:US
Mailing Address - Phone:337-463-6823
Mailing Address - Fax:
Practice Address - Street 1:1780 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-5306
Practice Address - Country:US
Practice Address - Phone:337-239-4249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11249183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy