Provider Demographics
NPI:1851115547
Name:BLALOCK, MATTHEW (PHARMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
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:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645-0217
Mailing Address - Country:US
Mailing Address - Phone:601-657-8051
Mailing Address - Fax:601-657-8049
Practice Address - Street 1:PO BOX 217
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MS
Practice Address - Zip Code:39645-0217
Practice Address - Country:US
Practice Address - Phone:601-657-8051
Practice Address - Fax:601-657-8049
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-12682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist