Provider Demographics
NPI:1801105291
Name:LORD, BLAKE MARK (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:MARK
Last Name:LORD
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 1:625 KNIGHTS BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-5215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5339 OLD HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2431
Practice Address - Country:US
Practice Address - Phone:770-924-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025563183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist