Provider Demographics
NPI:1164593885
Name:BURDINE, III, WILLIAM N (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:N
Last Name:BURDINE, III
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10831 DEL RIO RD
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91978-1215
Mailing Address - Country:US
Mailing Address - Phone:619-670-6257
Mailing Address - Fax:
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:SUITE #114
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:619-287-5035
Practice Address - Fax:619-287-5098
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA31975OtherR.PH LICENSE NO.