1679863575 NPI number — BURKE FAMILY PHARMACY INC

Table of content: (NPI 1679863575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679863575 NPI number — BURKE FAMILY PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURKE FAMILY PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BURKE FAMILY PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679863575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
722 FAIRMONT PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77504-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-243-6262
Provider Business Mailing Address Fax Number:
832-243-6692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
722 FAIRMONT PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77504-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-243-6262
Provider Business Practice Location Address Fax Number:
832-243-6692
Provider Enumeration Date:
04/12/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CAMERON
Authorized Official First Name:
TROY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
409-498-0065

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  27402 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 146472 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2129931 . This is a "PK" identifier . This identifiers is of the category "OTHER".