Provider Demographics
NPI:1609910090
Name:ANTLE, WILLIAM DOUGLAS (R PH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:ANTLE
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 THOUSAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2701
Mailing Address - Country:US
Mailing Address - Phone:502-456-4999
Mailing Address - Fax:
Practice Address - Street 1:2200 DUNDEE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1828
Practice Address - Country:US
Practice Address - Phone:502-452-2678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1819448OtherNABP NUMBER
KY54023585Medicaid
KY0495270001Medicare ID - Type Unspecified