Provider Demographics
NPI:1770134744
Name:EDENHOLM, COLIN (RPH)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:EDENHOLM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-3759
Mailing Address - Country:US
Mailing Address - Phone:406-782-5471
Mailing Address - Fax:406-782-5361
Practice Address - Street 1:2611 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-3759
Practice Address - Country:US
Practice Address - Phone:406-782-5471
Practice Address - Fax:406-782-5361
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-58476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
43231315OtherWALGREENS