Provider Demographics
NPI:1083619415
Name:BLOSS PHARMACY, INC.
Entity Type:Organization
Organization Name:BLOSS PHARMACY, INC.
Other - Org Name:BLOSS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCTISH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:570-638-2820
Mailing Address - Street 1:2 RIVERSIDE PLAZA
Mailing Address - Street 2:
Mailing Address - City:BLOSSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16912-1137
Mailing Address - Country:US
Mailing Address - Phone:570-638-2820
Mailing Address - Fax:570-638-3642
Practice Address - Street 1:2 RIVERSIDE PLAZA
Practice Address - Street 2:
Practice Address - City:BLOSSBURG
Practice Address - State:PA
Practice Address - Zip Code:16912-1137
Practice Address - Country:US
Practice Address - Phone:570-638-2820
Practice Address - Fax:570-638-3642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP411873L3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102574237Medicaid
2128878OtherPK
PA1019712410001Medicaid