=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124867973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDINA RADAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2024
-----------------------------------------------------
Last Update Date | 05/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1688 N PERRIS BLVD
-----------------------------------------------------
City | PERRIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92571-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-943-6868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 463 AUTUMN LN
-----------------------------------------------------
City | BANNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92220-3370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-223-0614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 47458
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------