Provider Demographics
NPI:1548519465
Name:WHITE, WANDA MICHELE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:MICHELE
Last Name:WHITE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 W SHORE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-3367
Mailing Address - Country:US
Mailing Address - Phone:770-907-1341
Mailing Address - Fax:
Practice Address - Street 1:1109 W SHORE DR
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-3367
Practice Address - Country:US
Practice Address - Phone:770-907-1341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist