Healthcare Provider Details

I. General information

NPI: 1619561131
Provider Name (Legal Business Name): ELIJAH SETH WHITAKER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 HIGHWAY 42 E
BEDFORD KY
40006-7624
US

IV. Provider business mailing address

4143 RESERVOIR AVE
LOUISVILLE KY
40213-2038
US

V. Phone/Fax

Practice location:
  • Phone: 502-255-3540
  • Fax: 502-255-3615
Mailing address:
  • Phone: 859-408-6796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number019362
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: