Provider Demographics
NPI:1679896773
Name:WHITE, MARK HEDGE (RPH, PD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:HEDGE
Last Name:WHITE
Suffix:
Gender:M
Credentials:RPH, PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 BUFORD HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340
Mailing Address - Country:US
Mailing Address - Phone:770-455-4433
Mailing Address - Fax:770-454-9144
Practice Address - Street 1:5705 BUFORD HWY NE
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-1206
Practice Address - Country:US
Practice Address - Phone:770-455-4433
Practice Address - Fax:770-454-9144
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13275183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist