Provider Demographics
NPI:1508165507
Name:ETHEREDGE, GEORGE NEWTON
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:NEWTON
Last Name:ETHEREDGE
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 1:115 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-9776
Mailing Address - Country:US
Mailing Address - Phone:828-337-1393
Mailing Address - Fax:
Practice Address - Street 1:1001 PATTON AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-3603
Practice Address - Country:US
Practice Address - Phone:828-252-1836
Practice Address - Fax:828-253-4783
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist