Provider Demographics
NPI:1114207669
Name:BURTON, CAROLYN (RPH)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BURTON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8709 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HICKORY HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60457-1355
Mailing Address - Country:US
Mailing Address - Phone:708-257-7290
Mailing Address - Fax:
Practice Address - Street 1:1 E OGDEN AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1339
Practice Address - Country:US
Practice Address - Phone:708-257-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036395183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361924025256Medicaid