Provider Demographics
NPI:1477629665
Name:EDMUNDSON, SCOTT A (RPH)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:EDMUNDSON
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 1:312 CAVITT AVE
Mailing Address - Street 2:
Mailing Address - City:TRAFFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15085-1065
Mailing Address - Country:US
Mailing Address - Phone:412-372-5493
Mailing Address - Fax:412-372-5493
Practice Address - Street 1:312 CAVITT AVE
Practice Address - Street 2:
Practice Address - City:TRAFFORD
Practice Address - State:PA
Practice Address - Zip Code:15085-1065
Practice Address - Country:US
Practice Address - Phone:412-372-5493
Practice Address - Fax:412-372-9543
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410571L3336C0003X
PARP041059L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018255900001Medicaid
3936549OtherNCPDP