Provider Demographics
NPI:1972717072
Name:BLANTON, MICHELLE DUVALL (DPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DUVALL
Last Name:BLANTON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-2904
Mailing Address - Country:US
Mailing Address - Phone:731-784-3610
Mailing Address - Fax:731-784-9989
Practice Address - Street 1:1616 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-2904
Practice Address - Country:US
Practice Address - Phone:731-784-3610
Practice Address - Fax:731-784-9989
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202009368OtherPHARMACIST LICENSE
TN8375OtherDOCTOR OF PHARMACY LICENS