Provider Demographics
NPI:1417537994
Name:BLACKFORD, GLEN RUSSEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:RUSSEL
Last Name:BLACKFORD
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 1:345 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-1806
Mailing Address - Country:US
Mailing Address - Phone:419-562-4222
Mailing Address - Fax:419-562-4516
Practice Address - Street 1:345 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1806
Practice Address - Country:US
Practice Address - Phone:419-562-4222
Practice Address - Fax:419-562-4516
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03109939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist