Healthcare Provider Details

I. General information

NPI: 1285801639
Provider Name (Legal Business Name): JOHANNES HENDRIK BLOM R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/24/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LEXINGTON AVE
MANSFIELD OH
44907-2632
US

IV. Provider business mailing address

1482 N LEXINGTON SPRINGMILL RD APT 1320
ONTARIO OH
44906-1277
US

V. Phone/Fax

Practice location:
  • Phone: 419-756-7023
  • Fax: 419-756-1532
Mailing address:
  • Phone: 419-756-7023
  • Fax: 419-756-1532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03442154
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: