Provider Demographics
NPI:1245457373
Name:BLACKWELL, CHARLES D (PHARM D)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10225 MATOCA WAY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-1379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6204 BALCONES DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4214
Practice Address - Country:US
Practice Address - Phone:512-427-9448
Practice Address - Fax:512-302-3928
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist