Provider Demographics
NPI:1033434246
Name:BURNETT, ROGER C
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:C
Last Name:BURNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 PEPPERELL PKWY
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5548
Mailing Address - Country:US
Mailing Address - Phone:334-745-3632
Mailing Address - Fax:334-749-3204
Practice Address - Street 1:1713 PEPPERELL PKWY
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5548
Practice Address - Country:US
Practice Address - Phone:334-745-3632
Practice Address - Fax:334-749-3204
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7357OtherSTATE LICENSE #