Provider Demographics
NPI:1194019356
Name:BRESLOW, EDWARD R
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:R
Last Name:BRESLOW
Suffix:
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 1:4028 WARDS RD
Mailing Address - Street 2:TARGET PHARMACY T1275
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2944
Mailing Address - Country:US
Mailing Address - Phone:434-239-7092
Mailing Address - Fax:434-239-7092
Practice Address - Street 1:4028 WARDS RD
Practice Address - Street 2:TARGET PHARMACY T1275
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2944
Practice Address - Country:US
Practice Address - Phone:434-239-7092
Practice Address - Fax:434-239-7092
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011951183500000X
FLPS0025706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist