Provider Demographics
NPI:1922216241
Name:BLACKSTONE, SAM N JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:N
Last Name:BLACKSTONE
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2801 GLENEAGLES DR
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-7204
Mailing Address - Country:US
Mailing Address - Phone:972-875-6521
Mailing Address - Fax:972-875-2677
Practice Address - Street 1:718 W LAMPASAS ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-4534
Practice Address - Country:US
Practice Address - Phone:972-875-6521
Practice Address - Fax:972-875-2677
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18204183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist