Provider Demographics
NPI:1669820494
Name:EDLUND, DEREK (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:EDLUND
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1416
Mailing Address - Country:US
Mailing Address - Phone:231-924-2360
Mailing Address - Fax:
Practice Address - Street 1:819 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1416
Practice Address - Country:US
Practice Address - Phone:231-924-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040792183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist