Provider Demographics
NPI:1053901272
Name:BLANTON, MARK LEE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LEE
Last Name:BLANTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 CLOVERLEAF SQ STE A1
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-3074
Mailing Address - Country:US
Mailing Address - Phone:276-523-2100
Mailing Address - Fax:276-523-2101
Practice Address - Street 1:310 CLOVERLEAF SQ STE A1
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3074
Practice Address - Country:US
Practice Address - Phone:276-523-2100
Practice Address - Fax:276-523-2101
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02020100243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy