Provider Demographics
NPI:1326643628
Name:DE BLAQUIERE SUDICK, PATRICIA A (RPH)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:DE BLAQUIERE SUDICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:PATRICIA
Other - Middle Name:A
Other - Last Name:DE BLAQUIERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1817 RIVERSIDE RD.
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856
Mailing Address - Country:US
Mailing Address - Phone:208-448-1633
Mailing Address - Fax:208-448-0344
Practice Address - Street 1:1817 RIVERSIDE RD.
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856
Practice Address - Country:US
Practice Address - Phone:208-448-2407
Practice Address - Fax:208-448-0344
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5228183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist