Provider Demographics
NPI:1245581255
Name:VAN BUREN, DOMONIQUE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DOMONIQUE
Middle Name:
Last Name:VAN BUREN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 E RIVER PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-3486
Mailing Address - Country:US
Mailing Address - Phone:601-500-7660
Mailing Address - Fax:
Practice Address - Street 1:805 E RIVER PL
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-3486
Practice Address - Country:US
Practice Address - Phone:601-500-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.020307183500000X
MST-15181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist