Provider Demographics
NPI:1629415815
Name:BLUE, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:BLUE
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 1:456 BRIDGEMILL DR
Mailing Address - Street 2:
Mailing Address - City:EAST DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31027-8313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 HILLCREST PKWY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-4366
Practice Address - Country:US
Practice Address - Phone:478-277-3085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist