Provider Demographics
NPI:1457740037
Name:BLOSSOM, DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BLOSSOM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22525 JULIE DR
Mailing Address - Street 2:
Mailing Address - City:KASILOF
Mailing Address - State:AK
Mailing Address - Zip Code:99610
Mailing Address - Country:US
Mailing Address - Phone:907-398-7137
Mailing Address - Fax:
Practice Address - Street 1:299 N BINKLEY ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7523
Practice Address - Country:US
Practice Address - Phone:907-262-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2282183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist