Provider Demographics
NPI:1245509306
Name:BLACKWELL, EUGENE C JR
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:C
Last Name:BLACKWELL
Suffix:JR
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 1:21351 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-3008
Mailing Address - Country:US
Mailing Address - Phone:815-464-0524
Mailing Address - Fax:
Practice Address - Street 1:21351 GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-3008
Practice Address - Country:US
Practice Address - Phone:815-464-0524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist