Provider Demographics
NPI:1164518163
Name:BURKE CENTER
Entity Type:Organization
Organization Name:BURKE CENTER
Other - Org Name:EAST TEXAS BEHAVIORAL HEALTHCARE NETWORK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIESCHANG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:936-634-5664
Mailing Address - Street 1:2704 HOMER ALTO RD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-8750
Mailing Address - Country:US
Mailing Address - Phone:800-564-6701
Mailing Address - Fax:800-564-7591
Practice Address - Street 1:2704 HOMER ALTO RD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-8750
Practice Address - Country:US
Practice Address - Phone:800-564-6701
Practice Address - Fax:800-564-7591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX229283336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145375Medicaid
2096453OtherPK