Provider Demographics
NPI:1538293717
Name:WHITEHEAD, ELLEN MICHELLE ROBERSON (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:MICHELLE ROBERSON
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2574 BOB LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-7220
Mailing Address - Country:US
Mailing Address - Phone:423-543-9723
Mailing Address - Fax:
Practice Address - Street 1:920 BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2315
Practice Address - Country:US
Practice Address - Phone:423-542-4925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000011750183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist