Provider Demographics
NPI:1053713974
Name:PEDALINE, JOSEPH (R,PH,)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PEDALINE
Suffix:
Gender:M
Credentials:R,PH,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 W WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-2600
Mailing Address - Country:US
Mailing Address - Phone:336-280-1290
Mailing Address - Fax:336-852-7083
Practice Address - Street 1:4424 W WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-2600
Practice Address - Country:US
Practice Address - Phone:336-280-1290
Practice Address - Fax:336-852-7083
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist