1326643628 NPI number — MS. PATRICIA A DE BLAQUIERE SUDICK RPH

Table of content: MS. PATRICIA A DE BLAQUIERE SUDICK RPH (NPI 1326643628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326643628 NPI number — MS. PATRICIA A DE BLAQUIERE SUDICK RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE BLAQUIERE SUDICK
Provider First Name:
PATRICIA
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DE BLAQUIERE
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326643628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1817 RIVERSIDE RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRIEST RIVER
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-448-1633
Provider Business Mailing Address Fax Number:
208-448-0344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1817 RIVERSIDE RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRIEST RIVER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-448-2407
Provider Business Practice Location Address Fax Number:
208-448-0344
Provider Enumeration Date:
12/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  P5228 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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