Provider Demographics
NPI:1063295319
Name:PORTER, BLAKE ANTHONY (RPH)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANTHONY
Last Name:PORTER
Suffix:
Gender:
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 QUAKER RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1718
Mailing Address - Country:US
Mailing Address - Phone:518-798-0262
Mailing Address - Fax:
Practice Address - Street 1:190 QUAKER RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1718
Practice Address - Country:US
Practice Address - Phone:518-798-0262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist