Provider Demographics
NPI:1073947784
Name:BLAYLOCK, KRISTOPHER BRENT (RPH)
Entity Type:Individual
Prefix:MR
First Name:KRISTOPHER
Middle Name:BRENT
Last Name:BLAYLOCK
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 1:801 BENTON RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3743
Mailing Address - Country:US
Mailing Address - Phone:318-742-3509
Mailing Address - Fax:318-742-7730
Practice Address - Street 1:801 BENTON RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-742-3509
Practice Address - Fax:318-742-7730
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LALA 15947OtherPHARMACIST LA 15947