Provider Demographics
NPI:1508160839
Name:EDMONDSON, MICHAEL SCOTT (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:EDMONDSON
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 1:1245 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1680
Mailing Address - Country:US
Mailing Address - Phone:541-526-1771
Mailing Address - Fax:541-504-5476
Practice Address - Street 1:1245 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1680
Practice Address - Country:US
Practice Address - Phone:541-526-1771
Practice Address - Fax:541-504-5476
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9008183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist