MEDICARE: MICHELLE BLALOCK PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	RPH0022684	GA

General Provider Information

NPI Number	:	1598399131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE BLALOCK PHARMD

Provider Business Mailing Address
First Line	:	3159 QUINN PL
Second Line	:
City	:	CHAMBLEE
State	:	GA
Zip	:	30341-4116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3871 PEACHTREE RD NE
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-3300
Country	:	US
Telephone Number	:	404-240-2812
Fax Number	:	404-240-2814

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2020
Last Update Date	:	02/22/2020

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