Provider Demographics
NPI:1649216946
Name:BLACKWELL, ROGER D (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 ENTERPRISE BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6300
Mailing Address - Country:US
Mailing Address - Phone:864-454-0888
Mailing Address - Fax:864-454-1130
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE A12
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-2369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8717OtherSC PHARMACIST IN CHARGE