Provider Demographics
NPI:1679357545
Name:BLAKELY, JEANINE ELIZABETH (RPH)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:ELIZABETH
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3964
Mailing Address - Country:US
Mailing Address - Phone:843-545-8500
Mailing Address - Fax:866-507-1763
Practice Address - Street 1:810 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3964
Practice Address - Country:US
Practice Address - Phone:843-545-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC75591835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric