Provider Demographics
NPI:1710526223
Name:BLACKMORE, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BLACKMORE
Suffix:
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 1:6551 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-4521
Mailing Address - Country:US
Mailing Address - Phone:323-702-3811
Mailing Address - Fax:
Practice Address - Street 1:27177 STATE HIGHWAY 189
Practice Address - Street 2:
Practice Address - City:BLUE JAY
Practice Address - State:CA
Practice Address - Zip Code:92317-0017
Practice Address - Country:US
Practice Address - Phone:909-336-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist