Provider Demographics
NPI:1750650883
Name:BLACKBURN, BOB L (DPH)
Entity Type:Individual
Prefix:MR
First Name:BOB
Middle Name:L
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13806 E 94TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4566
Mailing Address - Country:US
Mailing Address - Phone:918-272-2827
Mailing Address - Fax:
Practice Address - Street 1:13806 E 94TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4566
Practice Address - Country:US
Practice Address - Phone:918-272-2827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist