Provider Demographics
NPI:1164971743
Name:EDWARDS, LARRY (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:EDWARDS
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 1:96 KESSEL CT
Mailing Address - Street 2:#35
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6254
Mailing Address - Country:US
Mailing Address - Phone:414-690-6310
Mailing Address - Fax:
Practice Address - Street 1:208 S WEST ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1681
Practice Address - Country:US
Practice Address - Phone:920-324-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI734740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist