Provider Demographics
NPI:1013225564
Name:AMELUNG, EDWIN WALTER JR
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:WALTER
Last Name:AMELUNG
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-3407
Mailing Address - Country:US
Mailing Address - Phone:662-453-6685
Mailing Address - Fax:
Practice Address - Street 1:306 E SUNFLOWER RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2732
Practice Address - Country:US
Practice Address - Phone:662-843-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-7374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist