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General NPI Number Information
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NPI Number | 1932480498
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Entity Type | Individual
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Provider Name | BEN D BLACKBURN DPH
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Gender | Male
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Dates
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Enumeration Date | 08/29/2011
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Last Update Date | 08/29/2011
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Provider Practice Location Address
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Address Line | 16657 E 122ND ST N
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City | COLLINSVILLE
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State | OK
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Zip | 74021-5180
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Country | US
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Telephone | 918-688-8578
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Fax |
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Provider Business Mailing Address
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Address Line | 12802 E 96TH ST N
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City | OWASSO
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State | OK
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Zip | 74055-5371
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Country | US
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Telephone | 918-272-7467
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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 | 12179
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License Number State | OK
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