Provider Demographics
NPI:1649153461
Name:EDMONDS-HART, SHANTAVIA
Entity type:Individual
Prefix:
First Name:SHANTAVIA
Middle Name:
Last Name:EDMONDS-HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:ROWESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29133-0032
Mailing Address - Country:US
Mailing Address - Phone:803-837-0527
Mailing Address - Fax:
Practice Address - Street 1:1800 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-7415
Practice Address - Country:US
Practice Address - Phone:919-968-1293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist