Provider Demographics
NPI:1114651825
Name:BURNSIDE, JONATHAN THOMAS (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:THOMAS
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1592 QUEEN RD
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-9214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10635 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:MARMET
Practice Address - State:WV
Practice Address - Zip Code:25315-1963
Practice Address - Country:US
Practice Address - Phone:304-951-9312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0013235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist