Provider Demographics
NPI:1780299479
Name:BLUM, KATHLEEN BRADLEY (RPH)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BRADLEY
Last Name:BLUM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4997 ROUTE 61
Mailing Address - Street 2:
Mailing Address - City:ZWINGLE
Mailing Address - State:IA
Mailing Address - Zip Code:52079-9623
Mailing Address - Country:US
Mailing Address - Phone:563-557-2950
Mailing Address - Fax:
Practice Address - Street 1:8456 PEOSTA COMMERCIAL CT
Practice Address - Street 2:
Practice Address - City:PEOSTA
Practice Address - State:IA
Practice Address - Zip Code:52068-7123
Practice Address - Country:US
Practice Address - Phone:563-557-2950
Practice Address - Fax:563-557-2955
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17425-40183500000X
IN26015901A183500000X
IA16733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist