Provider Demographics
NPI:1427176312
Name:WHITE, MARTIN JACK (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JACK
Last Name:WHITE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 W VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2249
Mailing Address - Country:US
Mailing Address - Phone:909-422-0444
Mailing Address - Fax:909-422-0459
Practice Address - Street 1:518 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2249
Practice Address - Country:US
Practice Address - Phone:909-422-0444
Practice Address - Fax:909-422-0459
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist