Provider Demographics
NPI:1417205709
Name:BLACKMON, MICA LAUREN (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:MICA
Middle Name:LAUREN
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:KERSHAW
Mailing Address - State:SC
Mailing Address - Zip Code:29067-1834
Mailing Address - Country:US
Mailing Address - Phone:803-475-7370
Mailing Address - Fax:803-475-5531
Practice Address - Street 1:515 S HAMPTON ST
Practice Address - Street 2:
Practice Address - City:KERSHAW
Practice Address - State:SC
Practice Address - Zip Code:29067-1834
Practice Address - Country:US
Practice Address - Phone:803-475-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist