Provider Demographics
NPI:1417270323
Name:BURGOYNE, DOUGLAS (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:BURGOYNE
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 HIGHLAND DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2600
Mailing Address - Country:US
Mailing Address - Phone:801-865-1997
Mailing Address - Fax:
Practice Address - Street 1:4190 HIGHLAND DR
Practice Address - Street 2:SUITE 250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2600
Practice Address - Country:US
Practice Address - Phone:801-865-1997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275563-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist