Provider Demographics
NPI:1629226964
Name:BURLESON, TAI (PHARMD)
Entity Type:Individual
Prefix:
First Name:TAI
Middle Name:
Last Name:BURLESON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5375 STARBOARD ST UNIT 209
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6907
Mailing Address - Country:US
Mailing Address - Phone:402-578-7066
Mailing Address - Fax:
Practice Address - Street 1:5201 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-8208
Practice Address - Country:US
Practice Address - Phone:407-629-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS441571835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist