Provider Demographics
NPI:1780952317
Name:JUSTICE, EDWARD LEE III
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:LEE
Last Name:JUSTICE
Suffix:III
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 1:9665 BELLA DR
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-6271
Mailing Address - Country:US
Mailing Address - Phone:251-928-7762
Mailing Address - Fax:
Practice Address - Street 1:30957 MILL LN
Practice Address - Street 2:
Practice Address - City:SPANISH FORT
Practice Address - State:AL
Practice Address - Zip Code:36527-5453
Practice Address - Country:US
Practice Address - Phone:251-625-4654
Practice Address - Fax:251-625-4774
Is Sole Proprietor?:No
Enumeration Date:2011-12-10
Last Update Date:2011-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9097183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist