Provider Demographics
NPI:1174869119
Name:BLEDSOE, CARL
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5268 US HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-3169
Mailing Address - Country:US
Mailing Address - Phone:334-567-5136
Mailing Address - Fax:334-567-5142
Practice Address - Street 1:5268 US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-3169
Practice Address - Country:US
Practice Address - Phone:334-567-5136
Practice Address - Fax:334-567-5142
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7879OtherPHARMACIST LICENSE NUMBER