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General NPI Number Information
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NPI Number | 1275576837
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Entity Type | Individual
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Provider Name | BENJAMIN ROLAND BLACK PHARMD
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Gender | Male
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Dates
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Enumeration Date | 06/13/2006
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Last Update Date | 03/31/2023
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Provider Practice Location Address
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Address Line | 1704 MEADOWS LN
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City | VIDALIA
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State | GA
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Zip | 30474-8913
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Country | US
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Telephone | 912-537-4147
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Fax | 912-537-1914
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Provider Business Mailing Address
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Address Line | 3526 MOUNT VERNON ALSTON RD
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City | MOUNT VERNON
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State | GA
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Zip | 30445-2301
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Country | US
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Telephone | 912-594-6061
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH022024
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License Number State | GA
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