Provider Demographics
NPI:1366628513
Name:BLYSTONE, THEA MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:THEA
Middle Name:MARIE
Last Name:BLYSTONE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:THEA
Other - Middle Name:MARIE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1180 RIDGEMONT DRIVE
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335
Mailing Address - Country:US
Mailing Address - Phone:814-499-1010
Mailing Address - Fax:814-676-8716
Practice Address - Street 1:1180 RIDGEMONT DRIVE
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335
Practice Address - Country:US
Practice Address - Phone:814-499-1010
Practice Address - Fax:814-676-8716
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP441361183500000X, 1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist