Provider Demographics
NPI:1124340427
Name:BLOUNT, MARIO DAVID (RPH)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:DAVID
Last Name:BLOUNT
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 1:754 BRIGHTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1170
Mailing Address - Country:US
Mailing Address - Phone:304-842-7257
Mailing Address - Fax:
Practice Address - Street 1:754 BRIGHTRIDGE DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1170
Practice Address - Country:US
Practice Address - Phone:304-842-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-28
Last Update Date:2010-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist