Provider Demographics
NPI:1407020068
Name:BLACKWOOD, AUDREY (PHARMD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 5TH ST SE
Mailing Address - Street 2:
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723-9702
Mailing Address - Country:US
Mailing Address - Phone:218-666-6229
Mailing Address - Fax:218-666-6249
Practice Address - Street 1:10 5TH ST SE
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-9702
Practice Address - Country:US
Practice Address - Phone:218-666-6229
Practice Address - Fax:218-666-6249
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116902183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist