Provider Demographics
NPI:1992095657
Name:BLANTON, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BLANTON
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 1:560 MANCHESTER SQUARE SHPG CTR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-8779
Mailing Address - Country:US
Mailing Address - Phone:606-598-0414
Mailing Address - Fax:
Practice Address - Street 1:560 MANCHESTER SQUARE SHPG CTR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-8779
Practice Address - Country:US
Practice Address - Phone:606-598-0414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY014263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist