Provider Demographics
NPI:1417220559
Name:BURGESS, GARRETT M (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARRETT
Middle Name:M
Last Name:BURGESS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S THOR ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-5075
Mailing Address - Country:US
Mailing Address - Phone:509-532-4033
Mailing Address - Fax:509-532-4027
Practice Address - Street 1:400 S THOR ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-5075
Practice Address - Country:US
Practice Address - Phone:509-532-4033
Practice Address - Fax:509-532-4027
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA00016651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6024640Medicaid