Provider Demographics
NPI:1164918934
Name:BURCHETT, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BURCHETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 KEATS AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-5317
Mailing Address - Country:US
Mailing Address - Phone:757-653-6591
Mailing Address - Fax:
Practice Address - Street 1:1235 PECAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5037
Practice Address - Country:US
Practice Address - Phone:704-342-0584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist