Provider Demographics
NPI:1013201755
Name:EDGE, JUDITH R (RPH)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:R
Last Name:EDGE
Suffix:
Gender:F
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:W2618 STORY CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508-8702
Mailing Address - Country:US
Mailing Address - Phone:608-424-3504
Mailing Address - Fax:
Practice Address - Street 1:1019 RIVER ST STE 1
Practice Address - Street 2:BELLEVILLE HOMETOWN PHARMACY
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9181
Practice Address - Country:US
Practice Address - Phone:608-424-3364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-28
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11226-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist