Provider Demographics
NPI:1407200629
Name:BURNET PHARMACY, LLC
Entity Type:Organization
Organization Name:BURNET PHARMACY, LLC
Other - Org Name:BURNET PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:MOHAMMAD
Authorized Official - Last Name:HAMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-437-0102
Mailing Address - Street 1:3056 BURNET AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2466
Mailing Address - Country:US
Mailing Address - Phone:315-437-0102
Mailing Address - Fax:315-437-0136
Practice Address - Street 1:3056 BURNET AVE STE 12
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-2466
Practice Address - Country:US
Practice Address - Phone:315-437-0102
Practice Address - Fax:315-437-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
NY0345393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04408664Medicaid
2159618OtherPK