Provider Demographics
NPI:1710573282
Name:WHITE, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WHITE
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 1:3767 N DUNDANWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-5942
Mailing Address - Country:US
Mailing Address - Phone:317-679-4848
Mailing Address - Fax:
Practice Address - Street 1:1530 N SHADELAND AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3650
Practice Address - Country:US
Practice Address - Phone:317-356-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019752A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist