Provider Demographics
NPI:1366894909
Name:BLACKBURN, STARLING
Entity type:Individual
Prefix:
First Name:STARLING
Middle Name:
Last Name:BLACKBURN
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 1:1103 W SCREVEN STREET
Mailing Address - Street 2:RITE AID PHARMACY
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-0000
Mailing Address - Country:US
Mailing Address - Phone:229-263-4455
Mailing Address - Fax:229-263-6483
Practice Address - Street 1:1103 W SCREVEN STREET
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-0000
Practice Address - Country:US
Practice Address - Phone:229-263-4455
Practice Address - Fax:229-263-6483
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013377183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA013377OtherPHARMACIST