Provider Demographics
NPI:1306589643
Name:SELF, EDWIN IV (PHARMD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:SELF
Suffix:IV
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 1:307 CARRIAGE WAY
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-1303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 WALMART DR
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-6761
Practice Address - Country:US
Practice Address - Phone:706-485-4546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist