Provider Demographics
NPI:1053591057
Name:BLACKMON, GARY M (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:M
Last Name:BLACKMON
Suffix:
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 1:961 SE THORNHILL DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-4057
Mailing Address - Country:US
Mailing Address - Phone:772-879-4186
Mailing Address - Fax:
Practice Address - Street 1:1025 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5386
Practice Address - Country:US
Practice Address - Phone:772-335-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0020470183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist