Provider Demographics
NPI:1154505345
Name:BURNSIDE, COREY WAYNE
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:WAYNE
Last Name:BURNSIDE
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 1:3300 HWY 10 E
Mailing Address - Street 2:CASHWISE PHARMACY #15
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-0000
Mailing Address - Country:US
Mailing Address - Phone:218-236-0345
Mailing Address - Fax:218-236-0354
Practice Address - Street 1:3300 HWY 10 E
Practice Address - Street 2:CASHWISE PHARMACY #15
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-0000
Practice Address - Country:US
Practice Address - Phone:218-236-0345
Practice Address - Fax:218-236-0354
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist