Provider Demographics
NPI:1023268562
Name:WHITLEY, JACK WALTER (PHARM D)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:WALTER
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CRESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CANDLER
Mailing Address - State:NC
Mailing Address - Zip Code:28715-9652
Mailing Address - Country:US
Mailing Address - Phone:304-444-6158
Mailing Address - Fax:
Practice Address - Street 1:4 CRESTWOOD LN
Practice Address - Street 2:
Practice Address - City:CANDLER
Practice Address - State:NC
Practice Address - Zip Code:28715-9652
Practice Address - Country:US
Practice Address - Phone:304-444-6158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-20
Last Update Date:2008-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist