Healthcare Provider Details

I. General information

NPI: 1659294486
Provider Name (Legal Business Name): DREW BLACK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 NORRIS ST
ATOKA TN
38004-4909
US

IV. Provider business mailing address

142 NORRIS ST
ATOKA TN
38004-4909
US

V. Phone/Fax

Practice location:
  • Phone: 901-590-5464
  • Fax:
Mailing address:
  • Phone: 901-590-5464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26032167A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: