=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598659849
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISHA BLACKMON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2025
-----------------------------------------------------
Last Update Date | 06/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7686 CHARLOTTE HWY
-----------------------------------------------------
City | FORT MILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29707-7098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-548-9201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3785 LADSON RD APT 315
-----------------------------------------------------
City | LADSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29456-4356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 60595
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------