Provider Demographics
NPI:1841869849
Name:EDMISTON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:EBENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15931-4391
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1207 2ND ST
Practice Address - Street 2:
Practice Address - City:CRESSON
Practice Address - State:PA
Practice Address - Zip Code:16630-1164
Practice Address - Country:US
Practice Address - Phone:814-886-5667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP446828183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist