=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003945429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WARREN R WHALEY R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5121 S WESTNEDGE AVE
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-0404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-337-2133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9569 TREETOP DR
-----------------------------------------------------
City | GALESBURG
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49053-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-665-9041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302410880
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------