Healthcare Provider Details

I. General information

NPI: 1609863711
Provider Name (Legal Business Name): DARYL MADISON BLACKBURN RPH, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3643 N ROXBORO ST
DURHAM NC
27704-2702
US

IV. Provider business mailing address

3643 N ROXBORO ST
DURHAM NC
27704-2702
US

V. Phone/Fax

Practice location:
  • Phone: 919-470-8148
  • Fax: 919-470-7365
Mailing address:
  • Phone: 919-470-8148
  • Fax: 919-470-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6333
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: