Provider Demographics
NPI:1871194241
Name:WILLETT, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:WILLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 TINEY BROWNING BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-2425
Mailing Address - Country:US
Mailing Address - Phone:361-552-3525
Mailing Address - Fax:361-552-9616
Practice Address - Street 1:400 TINEY BROWNING BLVD
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-5215
Practice Address - Country:US
Practice Address - Phone:361-552-3525
Practice Address - Fax:361-552-9616
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist