Provider Demographics
NPI:1508615832
Name:BLACKBURN, MARY KATHRYN (PHARMD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:BARBOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:211 SAINT FRANCIS DRIVE
Mailing Address - Street 2:SUITE 01512
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703
Mailing Address - Country:US
Mailing Address - Phone:855-213-0007
Mailing Address - Fax:855-213-0052
Practice Address - Street 1:211 SAINT FRANCIS DRIVE
Practice Address - Street 2:SUITE 01512
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:855-213-0007
Practice Address - Fax:855-213-0052
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005033290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist