Provider Demographics
NPI:1952905887
Name:WHITE, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4631
Mailing Address - Country:US
Mailing Address - Phone:540-899-6874
Mailing Address - Fax:540-373-4031
Practice Address - Street 1:1511 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4631
Practice Address - Country:US
Practice Address - Phone:540-899-6874
Practice Address - Fax:540-373-4031
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist