Provider Demographics
NPI:1295144830
Name:BLACKBURN, JIMMY JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:BLACKBURN
Suffix:JR
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 1:1500 E DOWNING ST STE 6
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3234
Mailing Address - Country:US
Mailing Address - Phone:918-456-0694
Mailing Address - Fax:
Practice Address - Street 1:1500 E DOWNING ST STE 6
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3234
Practice Address - Country:US
Practice Address - Phone:918-456-0694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist