Provider Demographics
NPI:1508324518
Name:BLOMGREN, JOHN A (DPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BLOMGREN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:NICOMA PARK
Mailing Address - State:OK
Mailing Address - Zip Code:73066-0489
Mailing Address - Country:US
Mailing Address - Phone:405-769-8585
Mailing Address - Fax:405-769-8787
Practice Address - Street 1:10911 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:NICOMA PARK
Practice Address - State:OK
Practice Address - Zip Code:73066
Practice Address - Country:US
Practice Address - Phone:405-769-8585
Practice Address - Fax:405-769-8787
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist