Provider Demographics
NPI:1962077545
Name:BLOSSOM GARDEN BOUTIQUE
Entity type:Organization
Organization Name:BLOSSOM GARDEN BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:EMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:501-815-2482
Mailing Address - Street 1:104 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-3714
Mailing Address - Country:US
Mailing Address - Phone:501-267-7071
Mailing Address - Fax:501-267-7073
Practice Address - Street 1:104 W 3RD ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-3714
Practice Address - Country:US
Practice Address - Phone:501-267-7071
Practice Address - Fax:501-267-7073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies