Provider Demographics
NPI:1275179061
Name:EDWARDS, COLT J
Entity Type:Individual
Prefix:
First Name:COLT
Middle Name:J
Last Name:EDWARDS
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 1:1418 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3043
Mailing Address - Country:US
Mailing Address - Phone:814-381-6562
Mailing Address - Fax:
Practice Address - Street 1:821 E BISHOP ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTE
Practice Address - State:PA
Practice Address - Zip Code:16823-2319
Practice Address - Country:US
Practice Address - Phone:814-355-1548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP451154183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist