Provider Demographics
NPI:1588845580
Name:BURDICK, LISA A (RPH)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:BURDICK
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 1:84 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WEST SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12196-1739
Mailing Address - Country:US
Mailing Address - Phone:518-674-1309
Mailing Address - Fax:
Practice Address - Street 1:84 VALLEY DR
Practice Address - Street 2:
Practice Address - City:WEST SAND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12196-1739
Practice Address - Country:US
Practice Address - Phone:518-674-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-18
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY42833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY42833OtherNY STATE LICENSE