Provider Demographics
NPI:1508137613
Name:BLOUNT, EUGENE D
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:D
Last Name:BLOUNT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:D
Other - Last Name:BLOUNT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:JOAQUIN
Mailing Address - State:TX
Mailing Address - Zip Code:75954-0506
Mailing Address - Country:US
Mailing Address - Phone:936-269-3922
Mailing Address - Fax:936-269-9809
Practice Address - Street 1:13290 HIGHWAY 84 EAST
Practice Address - Street 2:
Practice Address - City:JOAQUIN
Practice Address - State:TX
Practice Address - Zip Code:75954
Practice Address - Country:US
Practice Address - Phone:936-269-3922
Practice Address - Fax:936-269-9809
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0077897001Medicare NSC