Provider Demographics
NPI:1649312778
Name:DAVID R. WHITLEY
Entity type:Organization
Organization Name:DAVID R. WHITLEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER , R.PH.
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-726-9592
Mailing Address - Street 1:501 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1636
Mailing Address - Country:US
Mailing Address - Phone:270-726-9592
Mailing Address - Fax:270-726-9881
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1636
Practice Address - Country:US
Practice Address - Phone:270-726-9592
Practice Address - Fax:270-726-9881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP016223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54018767Medicaid
1815072OtherNCPDP NUMBER
1815072OtherNCPDP NUMBER