Provider Demographics
NPI:1538611793
Name:BLIESE, KENNETH DALTON (CPHT, PRS)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DALTON
Last Name:BLIESE
Suffix:
Gender:M
Credentials:CPHT, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 SW BOND AVE STE 11501
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-418-9894
Mailing Address - Fax:503-418-9897
Practice Address - Street 1:3303 SW BOND AVE STE 11501
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-418-9894
Practice Address - Fax:503-418-9897
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT-0010020183700000X
FLRPT47760183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician