Provider Demographics
NPI:1790071876
Name:ETHERIEDGE, JOHN CHARLES
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:ETHERIEDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEMORY LANE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35079-4465
Mailing Address - Country:US
Mailing Address - Phone:205-647-8888
Mailing Address - Fax:205-647-8888
Practice Address - Street 1:1018 MAIN ST
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071
Practice Address - Country:US
Practice Address - Phone:205-631-8701
Practice Address - Fax:205-631-8705
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7818OtherSTATE OF ALABAMA