Provider Demographics
NPI:1639658909
Name:BURLINE, NICOLE MARIE (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BURLINE
Suffix:
Gender:F
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 1:388 HACADAM RD
Mailing Address - Street 2:
Mailing Address - City:SAUQUOIT
Mailing Address - State:NY
Mailing Address - Zip Code:13456-3513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4854 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-6206
Practice Address - Country:US
Practice Address - Phone:315-736-5232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI064201-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist