Provider Demographics
NPI:1487288155
Name:BLACKWELL, LEE JAY (RPH)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:JAY
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:TX
Mailing Address - Zip Code:77510-8627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12040 7TH ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:TX
Practice Address - Zip Code:77510-8627
Practice Address - Country:US
Practice Address - Phone:409-392-5719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302061835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist