Provider Demographics
NPI:1891977831
Name:ARCHIBALD, EDSON
Entity Type:Individual
Prefix:
First Name:EDSON
Middle Name:
Last Name:ARCHIBALD
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:PO BOX 672106
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-0802
Mailing Address - Country:US
Mailing Address - Phone:917-733-5098
Mailing Address - Fax:
Practice Address - Street 1:3464 JEROME AVE
Practice Address - Street 2:672106
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1097
Practice Address - Country:US
Practice Address - Phone:917-733-5098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-01
Last Update Date:2007-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist