=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528103363
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARION DEAN BLOSS DPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26245 HIGHWAY 82
-----------------------------------------------------
City | PARK HILL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74451-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-431-0505
-----------------------------------------------------
Fax | 918-431-1155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24143 HIGHWAY 82
-----------------------------------------------------
City | PARK HILL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74451-4011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-456-8432
-----------------------------------------------------
Fax | 918-431-1155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 7352
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------