Provider Demographics
NPI:1659771236
Name:WHITESIDE, TREVOR
Entity Type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:
Last Name:WHITESIDE
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 1:117 HESS RD
Mailing Address - Street 2:
Mailing Address - City:GRASONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21638-1304
Mailing Address - Country:US
Mailing Address - Phone:410-829-0286
Mailing Address - Fax:
Practice Address - Street 1:503 S CHERRY GROVE AVE
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-4244
Practice Address - Country:US
Practice Address - Phone:443-482-3981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist