Provider Demographics
NPI:1326776006
Name:BLOMS, JAKE (DOCTOR OF PHARMACY)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BLOMS
Suffix:
Gender:M
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8555 QUADAY AVE NE UNIT 303
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-6588
Mailing Address - Country:US
Mailing Address - Phone:701-263-5774
Mailing Address - Fax:
Practice Address - Street 1:1921 COBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-2100
Practice Address - Country:US
Practice Address - Phone:320-252-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN125717OtherPHARMACY LICENSE