Provider Demographics
NPI:1700209103
Name:BURKE, STEPHANIE
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:FREER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RP
Mailing Address - Street 1:1735 FORGE POND RD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-2936
Mailing Address - Country:US
Mailing Address - Phone:732-840-5638
Mailing Address - Fax:
Practice Address - Street 1:605 ROUTE 9
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-4827
Practice Address - Country:US
Practice Address - Phone:609-693-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01642200183500000X
NJ28RJ05120183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist