=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083619415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOSS PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2005
-----------------------------------------------------
Last Update Date | 11/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 RIVERSIDE PLAZA
-----------------------------------------------------
City | BLOSSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16912-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-638-2820
-----------------------------------------------------
Fax | 570-638-3642
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 RIVERSIDE PLAZA
-----------------------------------------------------
City | BLOSSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16912-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-638-2820
-----------------------------------------------------
Fax | 570-638-3642
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER MCTISH
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 570-638-2820
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP411873L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------