Provider Demographics
NPI:1508365958
Name:P. ROMAN BURK DPM PC
Entity Type:Organization
Organization Name:P. ROMAN BURK DPM PC
Other - Org Name:MOUNTAIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-855-0701
Mailing Address - Street 1:2667 E. GALA COURT SUITE 125
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-855-0701
Mailing Address - Fax:208-459-8628
Practice Address - Street 1:2667 E. GALA COURT SUITE 125
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-855-0701
Practice Address - Fax:208-268-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID47034RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1508365958Medicaid
2175811OtherPK