Provider Demographics
NPI:1700419769
Name:BURLESON PHARMACY LLC
Entity Type:Organization
Organization Name:BURLESON PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAHATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KANKANALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:817-720-5555
Mailing Address - Street 1:344 SW WILSHIRE BLVD STE P
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5343
Mailing Address - Country:US
Mailing Address - Phone:817-720-5555
Mailing Address - Fax:817-720-5554
Practice Address - Street 1:344 SW WILSHIRE BLVD STE P
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5343
Practice Address - Country:US
Practice Address - Phone:817-720-5555
Practice Address - Fax:817-720-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy