Provider Demographics
NPI:1639222748
Name:REDDITT, LEWIS ETHEREDGE II (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:ETHEREDGE
Last Name:REDDITT
Suffix:II
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5808 HIGHWAY 90
Mailing Address - Street 2:SUITE B
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-1643
Mailing Address - Country:US
Mailing Address - Phone:251-653-0720
Mailing Address - Fax:251-653-0748
Practice Address - Street 1:5808 HIGHWAY 90
Practice Address - Street 2:SUITE B
Practice Address - City:THEODORE
Practice Address - State:AL
Practice Address - Zip Code:36582-1643
Practice Address - Country:US
Practice Address - Phone:251-653-0720
Practice Address - Fax:251-653-0748
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7228183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1000001973Medicaid