Provider Demographics
NPI:1609329010
Name:BLASINGAME, TERRY LYNN
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LYNN
Last Name:BLASINGAME
Suffix:
Gender:F
Credentials:
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 167
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-0167
Mailing Address - Country:US
Mailing Address - Phone:909-336-3999
Mailing Address - Fax:909-336-3997
Practice Address - Street 1:28200 HIGHWAY 189 # N150
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-9700
Practice Address - Country:US
Practice Address - Phone:909-336-3999
Practice Address - Fax:909-336-3997
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist