Provider Demographics
NPI:1184228108
Name:BLANCHARD, CLIFFORD IV
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:
Last Name:BLANCHARD
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 NE EXPY NE STE B800
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-1828
Mailing Address - Country:US
Mailing Address - Phone:404-367-9111
Mailing Address - Fax:404-367-9199
Practice Address - Street 1:2700 NE EXPY NE STE B800
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-1828
Practice Address - Country:US
Practice Address - Phone:404-367-9111
Practice Address - Fax:404-367-9199
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024276333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH024276OtherGA BOARD OF PHARMACY