Provider Demographics
NPI:1730408865
Name:WILLARD, BLAIR ALLEN (RPH)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:ALLEN
Last Name:WILLARD
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 1:14060 27 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48094-2514
Mailing Address - Country:US
Mailing Address - Phone:586-786-7251
Mailing Address - Fax:
Practice Address - Street 1:23201 MARTER RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2729
Practice Address - Country:US
Practice Address - Phone:586-773-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist