Provider Demographics
NPI:1780969808
Name:BLOM, CASEY JO (PHARMD)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:JO
Last Name:BLOM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 BUSINESS 141 N
Mailing Address - Street 2:
Mailing Address - City:COLEMAN
Mailing Address - State:WI
Mailing Address - Zip Code:54112-9416
Mailing Address - Country:US
Mailing Address - Phone:920-897-5333
Mailing Address - Fax:920-897-5451
Practice Address - Street 1:633 BUSINESS 141 N
Practice Address - Street 2:
Practice Address - City:COLEMAN
Practice Address - State:WI
Practice Address - Zip Code:54112-9416
Practice Address - Country:US
Practice Address - Phone:920-897-5333
Practice Address - Fax:920-897-5451
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14567-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist