Provider Demographics
NPI:1669665394
Name:JOHNSON BLACKBURN
Entity Type:Organization
Organization Name:JOHNSON BLACKBURN
Other - Org Name:PAGES HOME STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-285-3134
Mailing Address - Street 1:111 E SOUTHERLAND ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2326
Mailing Address - Country:US
Mailing Address - Phone:910-285-3134
Mailing Address - Fax:
Practice Address - Street 1:111 E SOUTHERLAND ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-2326
Practice Address - Country:US
Practice Address - Phone:910-285-3134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20874332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies