Provider Demographics
NPI:1710263090
Name:BLACKELLAR, TRUDI-ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRUDI-ANN
Middle Name:
Last Name:BLACKELLAR
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 1:28100 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-3203
Mailing Address - Country:US
Mailing Address - Phone:239-495-8552
Mailing Address - Fax:
Practice Address - Street 1:10200 OLIVEWOOD WAY UNIT 39
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-7404
Practice Address - Country:US
Practice Address - Phone:954-636-9695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist