Provider Demographics
NPI:1932760071
Name:BLACKWOOD, JONATHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BLACKWOOD
Suffix:
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 1:104 ELIZA LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:SC
Mailing Address - Zip Code:29661-9074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 KNOX ABBOTT DR
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-3327
Practice Address - Country:US
Practice Address - Phone:803-223-0762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist