Provider Demographics
NPI:1982815031
Name:BLACKMAN, SIMONE VANESSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:VANESSA
Last Name:BLACKMAN
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 1:71 BEDFORDSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14467-9372
Mailing Address - Country:US
Mailing Address - Phone:585-359-9528
Mailing Address - Fax:
Practice Address - Street 1:535 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-5117
Practice Address - Country:US
Practice Address - Phone:585-266-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist