Provider Demographics
NPI:1407221856
Name:BURTON, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:BURTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E EDGEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-5807
Mailing Address - Country:US
Mailing Address - Phone:517-882-1142
Mailing Address - Fax:517-882-1172
Practice Address - Street 1:340 E EDGEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-5807
Practice Address - Country:US
Practice Address - Phone:517-882-1142
Practice Address - Fax:517-882-1172
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist