Provider Demographics
NPI:1386610855
Name:BLACKBURN, ROBERT WAYNE (PHARMD,MBA)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:PHARMD,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25515 LONE PINE CIR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5847
Mailing Address - Country:US
Mailing Address - Phone:949-735-5256
Mailing Address - Fax:949-643-9477
Practice Address - Street 1:1068 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-3731
Practice Address - Country:US
Practice Address - Phone:949-735-5256
Practice Address - Fax:949-643-9477
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30586183500000X, 1835P0018X
NV066481835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAY620Medicare PIN