1134694144 NPI number — BREANNE FAIRBURN PHARMD

Table of content: BREANNE FAIRBURN PHARMD (NPI 1134694144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134694144 NPI number — BREANNE FAIRBURN PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRBURN
Provider First Name:
BREANNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERS
Provider Other First Name:
BREANNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134694144
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLINTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70438-3688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-795-4116
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLINTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70438-3688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-795-4116
Provider Business Practice Location Address Fax Number:
985-795-4227
Provider Enumeration Date:
10/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  E-010809 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: PST.019246 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PST.019246 . This is a "LOUISIANA BOARD OF PHARMACY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: E-010809 . This is a "MISSISSIPPI BOARD OF PHARMACY" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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