Provider Demographics
NPI:1366841132
Name:BURGESS, ELIZABETH JANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JANE
Last Name:BURGESS
Suffix:
Gender:F
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:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-0057
Mailing Address - Country:US
Mailing Address - Phone:410-557-7717
Mailing Address - Fax:410-557-4336
Practice Address - Street 1:3714 NORRISVILLE RD
Practice Address - Street 2:
Practice Address - City:JARRETTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21084-1419
Practice Address - Country:US
Practice Address - Phone:410-557-7717
Practice Address - Fax:410-557-4336
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist