Provider Demographics
NPI:1578206108
Name:WHITE, MARIBETH CHARLOTTE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:CHARLOTTE
Last Name:WHITE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MARIBETH
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:4602 EASTPARK BLVD
Mailing Address - Street 2:PHARMACY
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718
Mailing Address - Country:US
Mailing Address - Phone:608-440-6357
Mailing Address - Fax:608-240-4266
Practice Address - Street 1:4602 EASTPARK BLVD
Practice Address - Street 2:PHARMACY
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718
Practice Address - Country:US
Practice Address - Phone:608-440-6357
Practice Address - Fax:608-240-4266
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17060-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist