Provider Demographics
NPI:1831673904
Name:WHITHAM, JEREMI
Entity type:Individual
Prefix:
First Name:JEREMI
Middle Name:
Last Name:WHITHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:TRIBUNE
Mailing Address - State:KS
Mailing Address - Zip Code:67879-0687
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:422 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TRIBUNE
Practice Address - State:KS
Practice Address - Zip Code:67879-7701
Practice Address - Country:US
Practice Address - Phone:620-376-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-13682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist