Provider Demographics
NPI:1710230230
Name:BLACKBURN, JAMES EDWARD JR
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARD
Last Name:BLACKBURN
Suffix:JR
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:PO BOX 11540
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1540
Mailing Address - Country:US
Mailing Address - Phone:540-809-6348
Mailing Address - Fax:
Practice Address - Street 1:150 SCOTT LN SPC A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8467
Practice Address - Country:US
Practice Address - Phone:307-201-1159
Practice Address - Fax:307-201-1553
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist