Provider Demographics
NPI:1558610980
Name:BURGESS, THERESA BURKE (RPH)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:BURKE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 E SPRAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4851
Mailing Address - Country:US
Mailing Address - Phone:509-534-7367
Mailing Address - Fax:509-534-0857
Practice Address - Street 1:4110 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-4851
Practice Address - Country:US
Practice Address - Phone:509-534-7367
Practice Address - Fax:509-534-0857
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00016007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist