Healthcare Provider Details

I. General information

NPI: 1508165697
Provider Name (Legal Business Name): CHARLES WILLIAM BLACKWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12216 N NC HIGHWAY 150
WINSTON SALEM NC
27127-9730
US

IV. Provider business mailing address

112 BERRYWOOD LN
LEXINGTON NC
27295-7302
US

V. Phone/Fax

Practice location:
  • Phone: 336-764-2211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9823
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: