Provider Demographics
NPI:1437747888
Name:WHITACRE, LAUREEN CARLSON (RPH)
Entity Type:Individual
Prefix:
First Name:LAUREEN
Middle Name:CARLSON
Last Name:WHITACRE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16948 LONDONBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1473
Mailing Address - Country:US
Mailing Address - Phone:574-276-2313
Mailing Address - Fax:
Practice Address - Street 1:120 SANFORD SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-5884
Practice Address - Country:US
Practice Address - Phone:574-970-6470
Practice Address - Fax:574-970-6473
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015315A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist