1437675063 NPI number — MIRANDA BURGESS BRUNSON PHARMD

Table of content: MIRANDA BURGESS BRUNSON PHARMD (NPI 1437675063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437675063 NPI number — MIRANDA BURGESS BRUNSON PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNSON
Provider First Name:
MIRANDA
Provider Middle Name:
BURGESS
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:
BURGESS
Provider Other First Name:
MIRANDA
Provider Other Middle Name:
LORRAINE
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:
1437675063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 SADDLEHORN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASLEY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29642-3060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-380-9536
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6414 STATE PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVELERS REST
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29690-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-834-7936
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2017

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:  37315 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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