Provider Demographics
NPI:1801237409
Name:BLACKWELL, DAVE W (RPH)
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:W
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 TAILFEATHER CT
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-6401
Mailing Address - Country:US
Mailing Address - Phone:813-235-6292
Mailing Address - Fax:
Practice Address - Street 1:1930 LAND O LAKES BLVD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-2999
Practice Address - Country:US
Practice Address - Phone:813-948-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist