Provider Demographics
NPI:1114185642
Name:BLACK, EARL ROBERT (RPH)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:ROBERT
Last Name:BLACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8219 TURNSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2137
Mailing Address - Country:US
Mailing Address - Phone:315-682-1920
Mailing Address - Fax:
Practice Address - Street 1:8219 TURNSTONE DR
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-2137
Practice Address - Country:US
Practice Address - Phone:315-682-1920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-31
Last Update Date:2008-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist