Provider Demographics
NPI:1396063665
Name:BLOOM, MARK STEFAN (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEFAN
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 1:129 EATON DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 KEDRON AVE
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:PA
Practice Address - Zip Code:19033-1308
Practice Address - Country:US
Practice Address - Phone:610-461-4665
Practice Address - Fax:610-461-7309
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP029248L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist