Provider Demographics
NPI:1003897612
Name:WYANT, EDWARD LEWIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:LEWIS
Last Name:WYANT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 JOHN DAY DR
Mailing Address - Street 2:
Mailing Address - City:GOLD HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97525-5525
Mailing Address - Country:US
Mailing Address - Phone:541-855-7512
Mailing Address - Fax:
Practice Address - Street 1:2825 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8332
Practice Address - Country:US
Practice Address - Phone:541-789-4251
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist