Provider Demographics
NPI:1629665344
Name:EDET, MBEREDEM CAROL
Entity Type:Individual
Prefix:
First Name:MBEREDEM
Middle Name:CAROL
Last Name:EDET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 DOWLEN RD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7226
Mailing Address - Country:US
Mailing Address - Phone:409-861-3413
Mailing Address - Fax:
Practice Address - Street 1:2950 DOWLEN RD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7226
Practice Address - Country:US
Practice Address - Phone:409-861-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist