Provider Demographics
NPI:1932957941
Name:BLACKMON, STACEY RENE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:RENE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 W MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-5395
Mailing Address - Country:US
Mailing Address - Phone:931-537-6337
Mailing Address - Fax:931-525-5668
Practice Address - Street 1:606 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-5395
Practice Address - Country:US
Practice Address - Phone:931-537-6337
Practice Address - Fax:931-525-5668
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN281083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy