1699097865 NPI number — MR. BENJAMIN DAVID BLITZBLAU PHARMD

Table of content: MR. BENJAMIN DAVID BLITZBLAU PHARMD (NPI 1699097865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699097865 NPI number — MR. BENJAMIN DAVID BLITZBLAU PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLITZBLAU
Provider First Name:
BENJAMIN
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699097865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 E RIVERSIDE BLVD
Provider Second Line Business Mailing Address:
KMART PHARMACY
Provider Business Mailing Address City Name:
LOVES PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61111-4742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-877-8059
Provider Business Mailing Address Fax Number:
815-282-4992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 E RIVERSIDE BLVD
Provider Second Line Business Practice Location Address:
KMART PHARMACY
Provider Business Practice Location Address City Name:
LOVES PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61111-4742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-877-8059
Provider Business Practice Location Address Fax Number:
815-282-4992
Provider Enumeration Date:
02/15/2010

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: 1835P1200X , with the licence number:  051290077 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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