Provider Demographics
NPI:1972687614
Name:EDGEWOOD DRUG INC
Entity Type:Organization
Organization Name:EDGEWOOD DRUG INC
Other - Org Name:EDGEWOOD LEGEND DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-896-1473
Mailing Address - Street 1:PO BOX 659
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:75117-0659
Mailing Address - Country:US
Mailing Address - Phone:903-986-1473
Mailing Address - Fax:903-896-1481
Practice Address - Street 1:115 N HOUSTON ST
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:TX
Practice Address - Zip Code:75117-2502
Practice Address - Country:US
Practice Address - Phone:903-896-1473
Practice Address - Fax:903-896-1481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX67823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2102565OtherPK
TX142867Medicaid
TX142867Medicaid