Provider Demographics
NPI:1134859424
Name:BLACKSTOCK, SCOTT RAY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RAY
Last Name:BLACKSTOCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 LEAH STAR RD
Mailing Address - Street 2:
Mailing Address - City:ASTOR
Mailing Address - State:FL
Mailing Address - Zip Code:32102-6915
Mailing Address - Country:US
Mailing Address - Phone:772-453-7766
Mailing Address - Fax:
Practice Address - Street 1:680 E BURLEIGH BLVD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-2208
Practice Address - Country:US
Practice Address - Phone:352-253-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS64010183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist