Provider Demographics
NPI:1275109340
Name:BLACKBURN DRUG LLC
Entity Type:Organization
Organization Name:BLACKBURN DRUG LLC
Other - Org Name:BLACKBURN DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:307-201-1159
Mailing Address - Street 1:PO BOX 11540
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1540
Mailing Address - Country:US
Mailing Address - Phone:307-201-1159
Mailing Address - Fax:307-201-1553
Practice Address - Street 1:545 N CACHE ST UNIT 10-S
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8685
Practice Address - Country:US
Practice Address - Phone:307-201-1159
Practice Address - Fax:307-201-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYFB9991034OtherDEA