Provider Demographics
NPI:1164029435
Name:BLEVINS, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:BLEVINS
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 1:915 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37825-6633
Mailing Address - Country:US
Mailing Address - Phone:423-626-5511
Mailing Address - Fax:
Practice Address - Street 1:915 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-6633
Practice Address - Country:US
Practice Address - Phone:423-626-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44426183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist