Provider Demographics
NPI:1487921250
Name:EDGEWORTH, CAROLYN A (RPH)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:EDGEWORTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9148 184TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-7600
Mailing Address - Country:US
Mailing Address - Phone:503-277-3629
Mailing Address - Fax:
Practice Address - Street 1:4404 S MERIDIAN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-9500
Practice Address - Country:US
Practice Address - Phone:253-770-6484
Practice Address - Fax:253-770-8967
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0009739183500000X
WAPH00039692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist