Provider Demographics
NPI:1285801639
Name:BLOM, JOHANNES HENDRIK (RPH)
Entity type:Individual
Prefix:MR
First Name:JOHANNES
Middle Name:HENDRIK
Last Name:BLOM
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 1:1943 BARTOW RD
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-4313
Mailing Address - Country:US
Mailing Address - Phone:707-839-2501
Mailing Address - Fax:707-839-0251
Practice Address - Street 1:1500 ANNA SPARKS WAY
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-4170
Practice Address - Country:US
Practice Address - Phone:707-839-0140
Practice Address - Fax:707-839-0251
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47797183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist