MEDICARE: DR. DUSTIN D EDWARDS PHARM D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	P5878	ID

General Provider Information

NPI Number	:	1003190596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DUSTIN D EDWARDS PHARM D.

Provider Business Mailing Address
First Line	:	9710 W BLACKPOOL CT
Second Line	:
City	:	STAR
State	:	ID
Zip	:	83669-5750
Country	:	US
Telephone Number	:	208-921-2525
Fax Number	:	208-459-2029

Provider Business Practice Location Address
First Line	:	1012 CLEVELAND BLVD
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-3852
Country	:	US
Telephone Number	:	208-455-1792
Fax Number	:	208-459-2029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2011
Last Update Date	:	10/03/2011

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