Provider Demographics
NPI:1316548209
Name:BLOOM, ELLEN EILEEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:EILEEN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6636 RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-2317
Mailing Address - Country:US
Mailing Address - Phone:410-487-0111
Mailing Address - Fax:410-582-9015
Practice Address - Street 1:6636 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2317
Practice Address - Country:US
Practice Address - Phone:410-487-0111
Practice Address - Fax:410-582-9015
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist