Provider Demographics
NPI:1134694144
Name:FAIRBURN, BREANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:FAIRBURN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-3688
Mailing Address - Country:US
Mailing Address - Phone:985-795-4116
Mailing Address - Fax:
Practice Address - Street 1:1900 MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-3688
Practice Address - Country:US
Practice Address - Phone:985-795-4116
Practice Address - Fax:985-795-4227
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-010809183500000X
LAPST.019246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPST.019246OtherLOUISIANA BOARD OF PHARMACY
MSE-010809OtherMISSISSIPPI BOARD OF PHARMACY