Provider Demographics
NPI:1518091198
Name:WHITE, JERROLD D (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERROLD
Middle Name:D
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 1:153 NW PARK SQ
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1335
Mailing Address - Country:US
Mailing Address - Phone:270-726-7626
Mailing Address - Fax:270-726-7879
Practice Address - Street 1:153 NW PARK SQ
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1335
Practice Address - Country:US
Practice Address - Phone:270-726-7626
Practice Address - Fax:270-726-7879
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005918183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist