Provider Demographics
NPI:1083218747
Name:WHITE, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 CORNWALLIS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3219
Mailing Address - Country:US
Mailing Address - Phone:609-234-2551
Mailing Address - Fax:
Practice Address - Street 1:700 BROAD ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:NJ
Practice Address - Zip Code:08077-1145
Practice Address - Country:US
Practice Address - Phone:856-829-1187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03371100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist