Provider Demographics
NPI:1043962244
Name:SIDOROV, EDWARD (PHARMD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SIDOROV
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 HENRY CULLINS RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5016
Mailing Address - Country:US
Mailing Address - Phone:425-773-9727
Mailing Address - Fax:
Practice Address - Street 1:1942 MONTAGUE AVENUE EXT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-9045
Practice Address - Country:US
Practice Address - Phone:864-223-7679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43326183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist