Individual
MR. BEN D BLACKBURN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPH
Contact information
Practice address
16657 E 122ND ST N, COLLINSVILLE, OK 74021-5180
(918) 688-8578
Mailing address
12802 E 96TH ST N, OWASSO, OK 74055-5371
(918) 272-7467
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
12179
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100234240
—
OK
05
—
100234240T
—
OK
Enumeration date
08/29/2011
Last updated
08/29/2011
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