Provider Demographics
NPI:1124193776
Name:BLACK, DOUGLAS A (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:BLACK
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 1:180 PINEHURST BLVD
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690
Mailing Address - Country:US
Mailing Address - Phone:740-773-1141
Mailing Address - Fax:
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8608
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist