1649312778 NPI number — DAVID R. WHITLEY

Table of content: (NPI 1649312778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649312778 NPI number — DAVID R. WHITLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID R. WHITLEY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WHITLEY'S PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649312778
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42276-1636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-726-9592
Provider Business Mailing Address Fax Number:
270-726-9881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42276-1636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-726-9592
Provider Business Practice Location Address Fax Number:
270-726-9881
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITLEY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
RANDALL
Authorized Official Title or Position:
OWNER , R.PH.
Authorized Official Telephone Number:
270-726-9592

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: P01622 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 54018767 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1815072 . This is a "NCPDP NUMBER" identifier . This identifiers is of the category "OTHER".




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