Provider Demographics
NPI:1417544610
Name:BLAYLOCK, PATRICIA EVELYN
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:EVELYN
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 HIGHWAY 62 65 N
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-2208
Mailing Address - Country:US
Mailing Address - Phone:870-741-2268
Mailing Address - Fax:870-741-3736
Practice Address - Street 1:611 HIGHWAY 62 65 N
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2208
Practice Address - Country:US
Practice Address - Phone:870-741-2118
Practice Address - Fax:870-741-3736
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist