Provider Demographics
NPI:1881014595
Name:BLACKMON, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BLACKMON
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 1:1040 CHESTERFIELD HWY
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-7010
Mailing Address - Country:US
Mailing Address - Phone:843-537-2741
Mailing Address - Fax:
Practice Address - Street 1:1040 CHESTERFIELD HWY
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-7010
Practice Address - Country:US
Practice Address - Phone:843-537-2741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist