Provider Demographics
NPI:1003503400
Name:EDMONDS, CARRIE ANN
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7020 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-7419
Mailing Address - Country:US
Mailing Address - Phone:208-853-3503
Mailing Address - Fax:208-853-4328
Practice Address - Street 1:7020 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-7419
Practice Address - Country:US
Practice Address - Phone:208-853-3503
Practice Address - Fax:208-853-4328
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCT20468183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician