Provider Demographics
NPI:1417256561
Name:EDELBLUTE, PHILLIP R (RPH)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:R
Last Name:EDELBLUTE
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 1:116 MUNFORD DR
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-2175
Mailing Address - Country:US
Mailing Address - Phone:919-630-7394
Mailing Address - Fax:
Practice Address - Street 1:2850 CAPITAL BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-2414
Practice Address - Country:US
Practice Address - Phone:919-421-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19876183500000X
OK8410183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK8410OtherOKLAHOMA STATE BOARD OF PHARMACY
NC19876OtherNORTH CAROLINA STATE BOARD OF PHARMACY