Provider Demographics
NPI:1891459301
Name:BLAKELY, TERESA LEDFORD (PHARMD,)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LEDFORD
Last Name:BLAKELY
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 1:1015 HOLLY CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:GA
Mailing Address - Zip Code:30563-1836
Mailing Address - Country:US
Mailing Address - Phone:706-499-1441
Mailing Address - Fax:
Practice Address - Street 1:1015 HOLLY CIR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:GA
Practice Address - Zip Code:30563-1836
Practice Address - Country:US
Practice Address - Phone:706-499-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist