Provider Demographics
NPI:1548578982
Name:BLOOM, BRIAN A (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:A
Last Name:BLOOM
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 1:8055 W BELL RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3806
Mailing Address - Country:US
Mailing Address - Phone:623-979-4484
Mailing Address - Fax:623-687-2372
Practice Address - Street 1:8055 W BELL RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3806
Practice Address - Country:US
Practice Address - Phone:623-979-4484
Practice Address - Fax:623-687-2372
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS015055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist