Provider Demographics
NPI:1558462150
Name:HENRY, EDMUND JR (RPN)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:
Last Name:HENRY
Suffix:JR
Gender:M
Credentials:RPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-0485
Mailing Address - Country:US
Mailing Address - Phone:386-752-7490
Mailing Address - Fax:
Practice Address - Street 1:619 SOUTH MARION STREET
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist