Provider Demographics
NPI:1568504520
Name:WHITLEY, DAVID RANDALL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RANDALL
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1636
Mailing Address - Country:US
Mailing Address - Phone:270-726-9592
Mailing Address - Fax:270-726-9881
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1636
Practice Address - Country:US
Practice Address - Phone:270-726-9592
Practice Address - Fax:270-726-9881
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist