Provider Demographics
NPI:1104005628
Name:BRYDEN, CHARLES EDWIN (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWIN
Last Name:BRYDEN
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 1:3400 STATE ROUTE 11
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-4714
Mailing Address - Country:US
Mailing Address - Phone:518-483-4110
Mailing Address - Fax:518-483-2815
Practice Address - Street 1:3400 STATE ROUTE 11
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-4714
Practice Address - Country:US
Practice Address - Phone:518-483-4110
Practice Address - Fax:518-483-2815
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31188183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00561995Medicaid