Provider Demographics
NPI:1285478719
Name:BLALOCK, SHANNON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-1925
Mailing Address - Country:US
Mailing Address - Phone:919-599-9455
Mailing Address - Fax:
Practice Address - Street 1:1116 US 70 HWY W
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-2546
Practice Address - Country:US
Practice Address - Phone:919-227-3917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist