Provider Demographics
NPI:1427192293
Name:BLOSSOM, JEFFREY E (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:E
Last Name:BLOSSOM
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 1:752 S FISCHER CIR
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-4619
Mailing Address - Country:US
Mailing Address - Phone:772-388-4636
Mailing Address - Fax:772-388-3032
Practice Address - Street 1:995 SEBASTIAN BLVD
Practice Address - Street 2:WINN DIXIE PHARMACY
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-4880
Practice Address - Country:US
Practice Address - Phone:772-388-4636
Practice Address - Fax:772-388-3032
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0020872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist