Provider Demographics
NPI:1851571350
Name:TAM, EDMUND (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 HORSEBLOCK RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2525
Mailing Address - Country:US
Mailing Address - Phone:631-286-9491
Mailing Address - Fax:631-286-9224
Practice Address - Street 1:2950 HORSEBLOCK RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2525
Practice Address - Country:US
Practice Address - Phone:631-286-9491
Practice Address - Fax:631-286-9224
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02277567Medicaid