Provider Demographics
NPI:1497966642
Name:WHITE, DOUG (RPH)
Entity Type:Individual
Prefix:
First Name:DOUG
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5556 BASSWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55373-9651
Mailing Address - Country:US
Mailing Address - Phone:763-477-6173
Mailing Address - Fax:
Practice Address - Street 1:3550 VICKSBURG LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1322
Practice Address - Country:US
Practice Address - Phone:763-553-2627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist