Healthcare Provider Details

I. General information

NPI: 1114245255
Provider Name (Legal Business Name): EDWARD LANE WORTHINGTON PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 LOS OSOS VALLEY RD
LOS OSOS CA
93402-3204
US

IV. Provider business mailing address

1110 LOS OSOS VALLEY RD
LOS OSOS CA
93402-3204
US

V. Phone/Fax

Practice location:
  • Phone: 805-528-5779
  • Fax: 805-528-8617
Mailing address:
  • Phone: 805-528-5779
  • Fax: 805-528-8617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number66632
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12886
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: