Provider Demographics
NPI:1720486095
Name:WHITE, GLORIA (RPH)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 ELKHART ROAD
Mailing Address - Street 2:C/O WALGREENS
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526
Mailing Address - Country:US
Mailing Address - Phone:574-875-0236
Mailing Address - Fax:
Practice Address - Street 1:4430 ELKHART ROAD
Practice Address - Street 2:C/O WALGREENS
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526
Practice Address - Country:US
Practice Address - Phone:574-875-0236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024947A183500000X
FLPS43696183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist