Provider Demographics
NPI:1699158543
Name:WHITE, ELICIA NICHOLE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ELICIA
Middle Name:NICHOLE
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 1:2204 PAVILION DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-224-1245
Mailing Address - Fax:423-224-3901
Practice Address - Street 1:2204 PAVILION DRIVE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-224-1245
Practice Address - Fax:423-224-3901
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214055183500000X
TN403171835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1699158543Medicaid