Provider Demographics
NPI:1003190596
Name:EDWARDS, DUSTIN D (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:D
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9710 W BLACKPOOL CT
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5750
Mailing Address - Country:US
Mailing Address - Phone:208-921-2525
Mailing Address - Fax:208-459-2029
Practice Address - Street 1:1012 CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-3852
Practice Address - Country:US
Practice Address - Phone:208-455-1792
Practice Address - Fax:208-459-2029
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist