Provider Demographics
NPI:1285126862
Name:BLACKMON, KISHA MONIQUE
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:MONIQUE
Last Name:BLACKMON
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 1:5730 WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2225
Mailing Address - Country:US
Mailing Address - Phone:267-644-9244
Mailing Address - Fax:
Practice Address - Street 1:5730 WOODCREST AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-2225
Practice Address - Country:US
Practice Address - Phone:267-644-9244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA30028491183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician