Basic Information
| Provider Information | |||||||||
| NPI: | 1104125095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKMON | ||||||||
| FirstName: | ALVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067877763 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 W HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067877763 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2011 | ||||||||
| LastUpdateDate: | 03/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835N0905X | 0202205702 | VA | Y | Pharmacy Service Providers | Pharmacist | Nuclear | 1835N0905X | 017025 | LA | N | Pharmacy Service Providers | Pharmacist | Nuclear |
No ID Information.