Provider Demographics
NPI:1821465964
Name:DOUGLAS, KELLIE WHITE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:WHITE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:SUSANNE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:JOHNSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29555-0240
Mailing Address - Country:US
Mailing Address - Phone:843-905-0200
Mailing Address - Fax:843-905-0201
Practice Address - Street 1:616 SOUTH WALNUT STREET
Practice Address - Street 2:
Practice Address - City:PAMPLICO
Practice Address - State:SC
Practice Address - Zip Code:29583-0000
Practice Address - Country:US
Practice Address - Phone:843-905-0200
Practice Address - Fax:843-905-0201
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36022183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist