Provider Demographics
NPI:1164710190
Name:BLOCKER, KELLEY JO (PHARM D)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:JO
Last Name:BLOCKER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MT. PLEASANT
Mailing Address - State:TN
Mailing Address - Zip Code:38474
Mailing Address - Country:US
Mailing Address - Phone:931-379-5000
Mailing Address - Fax:931-379-4276
Practice Address - Street 1:801 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TN
Practice Address - Zip Code:38474-1017
Practice Address - Country:US
Practice Address - Phone:931-379-5000
Practice Address - Fax:931-379-4276
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist