Provider Demographics
NPI:1477584704
Name:BLAYLOCK, RUSSELL MARION (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:MARION
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 CROMWELL AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-7027
Mailing Address - Country:US
Mailing Address - Phone:559-681-7876
Mailing Address - Fax:
Practice Address - Street 1:751 CROMWELL AVENUE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611
Practice Address - Country:US
Practice Address - Phone:559-681-7876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12607-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist