Healthcare Provider Details

I. General information

NPI: 1245135458
Provider Name (Legal Business Name): CODY MATTHEW BLACKBURN PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 KY ROUTE 321
PRESTONSBURG KY
41653-9113
US

IV. Provider business mailing address

5000 KY ROUTE 321
PRESTONSBURG KY
41653-9113
US

V. Phone/Fax

Practice location:
  • Phone: 606-886-8511
  • Fax:
Mailing address:
  • Phone: 606-886-8511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835E0208X
TaxonomyEmergency Medicine Pharmacist
License Number023174
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: