Healthcare Provider Details

I. General information

NPI: 1912253378
Provider Name (Legal Business Name): TIA BLOOM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 E BOISE AVE
BOISE ID
83706-5118
US

IV. Provider business mailing address

10318 W ARDYCE ST
BOISE ID
83704-5309
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-8340
  • Fax:
Mailing address:
  • Phone: 208-604-1609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP6671
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0013184
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: