Provider Demographics
NPI:1881903888
Name:BLACK, EDSEL RAY SR (RPH)
Entity type:Individual
Prefix:MR
First Name:EDSEL
Middle Name:RAY
Last Name:BLACK
Suffix:SR
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 1:184 W KYTLE ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-1330
Mailing Address - Country:US
Mailing Address - Phone:706-219-2626
Mailing Address - Fax:706-219-1253
Practice Address - Street 1:184 W KYTLE ST STE A
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-9607
Practice Address - Country:US
Practice Address - Phone:706-219-2626
Practice Address - Fax:706-219-1253
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-25
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH009632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist