Basic Information
| Provider Information | |||||||||
| NPI: | 1134210248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | PHARM D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1570 ASPEN DR | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744646011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182078939 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | RR 6 BOX 840 | ||||||||
| Address2: | |||||||||
| City: | STILWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749608703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968800 | ||||||||
| FaxNumber: | 9186968881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 09/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 13655 | OK | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.