Provider Demographics
NPI:1104109248
Name:BLACKWELL, JULIE ANN
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7755 W HOWE RD
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-7818
Mailing Address - Country:US
Mailing Address - Phone:517-896-0315
Mailing Address - Fax:
Practice Address - Street 1:3435 E SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4717
Practice Address - Country:US
Practice Address - Phone:517-351-0449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI302030786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist