Provider Demographics
NPI:1881287266
Name:CALDERON, BLAZE JUSTIN
Entity type:Individual
Prefix:
First Name:BLAZE
Middle Name:JUSTIN
Last Name:CALDERON
Suffix:
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 1:8036 MASSARD RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-7030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:551 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-6001
Practice Address - Country:US
Practice Address - Phone:479-996-8533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist