Provider Demographics
NPI:1932417292
Name:EDGE, DUSTIN TODD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:TODD
Last Name:EDGE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-9203
Mailing Address - Country:US
Mailing Address - Phone:910-624-2978
Mailing Address - Fax:
Practice Address - Street 1:4923 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3141
Practice Address - Country:US
Practice Address - Phone:910-423-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist