Provider Demographics
NPI:1154774776
Name:WHITE, JOHN R JR (PA-C, PHARMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:PA-C, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N RIVERPOINT BLVD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1610
Mailing Address - Country:US
Mailing Address - Phone:509-358-7731
Mailing Address - Fax:
Practice Address - Street 1:310 N RIVERPOINT BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1610
Practice Address - Country:US
Practice Address - Phone:509-358-7731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00017312183500000X
WAPA 10003784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No183500000XPharmacy Service ProvidersPharmacist