Provider Demographics
NPI:1508454463
Name:BLAYLOCK, THOMAS SETH
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:SETH
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17422 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:CALLAO
Mailing Address - State:VA
Mailing Address - Zip Code:22435-2420
Mailing Address - Country:US
Mailing Address - Phone:804-529-6230
Mailing Address - Fax:804-529-5267
Practice Address - Street 1:17422 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:CALLAO
Practice Address - State:VA
Practice Address - Zip Code:22435-2420
Practice Address - Country:US
Practice Address - Phone:804-529-6230
Practice Address - Fax:804-529-5267
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist