Provider Demographics
NPI:1518562933
Name:BLOOM, CORTNEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15047 AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4201
Mailing Address - Country:US
Mailing Address - Phone:225-744-8409
Mailing Address - Fax:225-744-8411
Practice Address - Street 1:15047 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-4201
Practice Address - Country:US
Practice Address - Phone:225-744-8409
Practice Address - Fax:225-744-8411
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST021812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1699213173OtherPHARMACIST