Healthcare Provider Details

I. General information

NPI: 1699082172
Provider Name (Legal Business Name): CELISA RUFUS BLACKMON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 UNION AVE
MEMPHIS TN
38104-3941
US

IV. Provider business mailing address

1810 UNION AVE
MEMPHIS TN
38104-3941
US

V. Phone/Fax

Practice location:
  • Phone: 901-272-6191
  • Fax: 901-272-6180
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number122557
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: