Provider Demographics
NPI:1992174247
Name:MCMAHON, EDWARD A (183500000X)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:A
Last Name:MCMAHON
Suffix:
Gender:M
Credentials:183500000X
Other - Prefix:MR
Other - First Name:EDWARD
Other - Middle Name:A
Other - Last Name:MCMAHON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:79795 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4756
Mailing Address - Country:US
Mailing Address - Phone:760-342-0656
Mailing Address - Fax:760-775-0367
Practice Address - Street 1:79795 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-4756
Practice Address - Country:US
Practice Address - Phone:760-342-0656
Practice Address - Fax:760-775-0367
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist