Provider Demographics
NPI:1538419619
Name:BLACKWELL, DEBRA
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6972 SANDHILL RD
Mailing Address - Street 2:
Mailing Address - City:KERSHAW
Mailing Address - State:SC
Mailing Address - Zip Code:29067-8288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 NORTH VAN LINGLE MUNGO BLVD
Practice Address - Street 2:
Practice Address - City:PAGELAND
Practice Address - State:SC
Practice Address - Zip Code:29728
Practice Address - Country:US
Practice Address - Phone:843-672-2420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist