Provider Demographics
NPI:1699507616
Name:BLACKBURN, ELBERT III (RPH)
Entity type:Individual
Prefix:
First Name:ELBERT
Middle Name:
Last Name:BLACKBURN
Suffix:III
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BRIAR LN
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-9285
Mailing Address - Country:US
Mailing Address - Phone:606-434-4837
Mailing Address - Fax:
Practice Address - Street 1:2104 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-1026
Practice Address - Country:US
Practice Address - Phone:606-878-7344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist