Healthcare Provider Details

I. General information

NPI: 1629954490
Provider Name (Legal Business Name): DEBORAH KAY BLOMSTROM RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16750 COUNTY ROAD 30
MAPLE GROVE MN
55311-4523
US

IV. Provider business mailing address

16750 COUNTY ROAD 30
MAPLE GROVE MN
55311-4523
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-1863
  • Fax:
Mailing address:
  • Phone: 763-416-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number115451
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: