Provider Demographics
NPI:1295841120
Name:GRACE, EDWARD EDMOND (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:EDMOND
Last Name:GRACE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 VILLA RD, APT #182 APARTMENT 517
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29615
Mailing Address - Country:US
Mailing Address - Phone:864-451-4250
Mailing Address - Fax:
Practice Address - Street 1:15 VILLA RD, APT #182
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-451-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS401351835P1200X
SC13911835P1200X
SC134911835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS40135OtherBOARD OF PHARMACY
SC13491OtherSC BOARD OF PHARMACY