Healthcare Provider Details

I. General information

NPI: 1659939759
Provider Name (Legal Business Name): CHARLOTTE WHITNEY WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

105 CAMDEN LAKE DR
MADISON MS
39110-7030
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-5211
  • Fax:
Mailing address:
  • Phone: 205-381-7048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number15878
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: