Provider Demographics
NPI:1265931372
Name:EDWARDS, CLIFFORD LEE SR
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:LEE
Last Name:EDWARDS
Suffix:SR
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 1:1029 WILLOW OAK LN APT 204
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3127
Mailing Address - Country:US
Mailing Address - Phone:615-336-5968
Mailing Address - Fax:
Practice Address - Street 1:5028 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3196
Practice Address - Country:US
Practice Address - Phone:731-686-9097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-04
Last Update Date:2018-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty