Provider Demographics
NPI:1760694392
Name:EDWARDS, ELAINE (RPH)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 RIVA RDG
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-4328
Mailing Address - Country:US
Mailing Address - Phone:618-466-8973
Mailing Address - Fax:618-466-8994
Practice Address - Street 1:1470 RIVA RDG
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-4328
Practice Address - Country:US
Practice Address - Phone:618-466-8973
Practice Address - Fax:618-466-8994
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-036661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist