Provider Demographics
NPI:1932480498
Name:BLACKBURN, BEN D (DPH)
Entity Type:Individual
Prefix:MR
First Name:BEN
Middle Name:D
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12802 E 96TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-5371
Mailing Address - Country:US
Mailing Address - Phone:918-272-7467
Mailing Address - Fax:
Practice Address - Street 1:16657 E 122ND ST N
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-5180
Practice Address - Country:US
Practice Address - Phone:918-688-8578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12179183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234240Medicaid
OK100234240TMedicaid