Healthcare Provider Details

I. General information

NPI: 1003897612
Provider Name (Legal Business Name): EDWARD LEWIS WYANT R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 E BARNETT RD
MEDFORD OR
97504-8332
US

IV. Provider business mailing address

8801 JOHN DAY DR
GOLD HILL OR
97525-5525
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-4251
  • Fax:
Mailing address:
  • Phone: 541-855-7512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9432
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: