Provider Demographics
NPI:1629364898
Name:BLACKMORE, STACI SANDLER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACI
Middle Name:SANDLER
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5865 SPOUT SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3448
Mailing Address - Country:US
Mailing Address - Phone:770-967-1210
Mailing Address - Fax:
Practice Address - Street 1:5865 SPOUT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-3448
Practice Address - Country:US
Practice Address - Phone:770-967-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-25
Last Update Date:2011-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist