Healthcare Provider Details

I. General information

NPI: 1013201755
Provider Name (Legal Business Name): JUDITH R EDGE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2011
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 RIVER ST STE 1 BELLEVILLE HOMETOWN PHARMACY
BELLEVILLE WI
53508-9181
US

IV. Provider business mailing address

W2618 STORY CREEK CIR
BELLEVILLE WI
53508-8702
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-3364
  • Fax:
Mailing address:
  • Phone: 608-424-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11226-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: