1598017477 NPI number — BLYTHE ASHLEY RETZLAFF PHARMD

Table of content: BLYTHE ASHLEY RETZLAFF PHARMD (NPI 1598017477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598017477 NPI number — BLYTHE ASHLEY RETZLAFF PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RETZLAFF
Provider First Name:
BLYTHE
Provider Middle Name:
ASHLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUTLER
Provider Other First Name:
BLYTHE
Provider Other Middle Name:
ASHLEY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598017477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 FOSTER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT JULIET
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37122-3198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-410-4051
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1627 HENTHORNE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MAUMEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43537-1370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-865-0337
Provider Business Practice Location Address Fax Number:
419-865-0629
Provider Enumeration Date:
10/03/2012

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:  03132100 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 37063 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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