=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073715942
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD C. BLUNDEN R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11050 MOUNT BELVEDERE BLVD
-----------------------------------------------------
City | FORT DRUM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13602-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-772-7698
-----------------------------------------------------
Fax | 315-772-4018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35672 SAYRE RD
-----------------------------------------------------
City | CARTHAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13619-8520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-493-6406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 037356
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------