Provider Demographics
NPI:1841458544
Name:WAITE, JEFFREY BLAINE (RPH)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BLAINE
Last Name:WAITE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 BAY ROAD
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482
Mailing Address - Country:US
Mailing Address - Phone:802-233-0202
Mailing Address - Fax:
Practice Address - Street 1:86 BAY ROAD
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482
Practice Address - Country:US
Practice Address - Phone:802-233-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2013-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT2474183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist