Provider Demographics
NPI:1538509948
Name:EDGE, LARRY W (RPH)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:W
Last Name:EDGE
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 1:2520 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-2031
Mailing Address - Country:US
Mailing Address - Phone:304-674-2412
Mailing Address - Fax:
Practice Address - Street 1:2520 VALLEY DR
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-2031
Practice Address - Country:US
Practice Address - Phone:304-674-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-29
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-19625183500000X
WVRP00006832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist