Provider Demographics
NPI:1376888784
Name:BLACKWELL, JOE BRYAN (RPH)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:BRYAN
Last Name:BLACKWELL
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 1:5443 LOCUST HILL RD
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-8639
Mailing Address - Country:US
Mailing Address - Phone:864-238-6285
Mailing Address - Fax:
Practice Address - Street 1:2801 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-2781
Practice Address - Country:US
Practice Address - Phone:864-609-7306
Practice Address - Fax:864-609-0889
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist