Provider Demographics
NPI:1336637180
Name:WHITEHEAD, DAVID NICHOLAS (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:NICHOLAS
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:PHARMACIST
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 10966
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96931-0966
Mailing Address - Country:US
Mailing Address - Phone:671-637-3323
Mailing Address - Fax:671-637-3316
Practice Address - Street 1:612 W MARINE CORPS DR STE 8
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-5629
Practice Address - Country:US
Practice Address - Phone:671-637-3323
Practice Address - Fax:671-637-3316
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPH0117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist