Provider Demographics
NPI:1063852440
Name:WHITE, SHELLY ANN (PD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 E RACE AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4662
Mailing Address - Country:US
Mailing Address - Phone:501-268-5315
Mailing Address - Fax:
Practice Address - Street 1:1540 E RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4662
Practice Address - Country:US
Practice Address - Phone:501-268-5315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07751183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist