Provider Demographics
NPI:1851672331
Name:BURLEY, TARA (PHARMD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BURLEY
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 1:22318 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1657
Mailing Address - Country:US
Mailing Address - Phone:248-486-5216
Mailing Address - Fax:248-486-5460
Practice Address - Street 1:22318 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1657
Practice Address - Country:US
Practice Address - Phone:248-486-5216
Practice Address - Fax:248-486-5460
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031863183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist