Provider Demographics
NPI:1780974238
Name:BLYE, ROOSEVELT ALONZO JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ROOSEVELT
Middle Name:ALONZO
Last Name:BLYE
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 1:1593 RACHEL DRIVE
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532
Mailing Address - Country:US
Mailing Address - Phone:228-392-0112
Mailing Address - Fax:
Practice Address - Street 1:200 WEST RAILROAD STREET SUITE B
Practice Address - Street 2:RITE AID
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-2269
Practice Address - Country:US
Practice Address - Phone:228-864-0334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist