Provider Demographics
NPI:1912397761
Name:BURT, PERCY
Entity Type:Individual
Prefix:
First Name:PERCY
Middle Name:
Last Name:BURT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 CARL D SILVER PKWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401
Mailing Address - Country:US
Mailing Address - Phone:540-786-7957
Mailing Address - Fax:540-548-7401
Practice Address - Street 1:1180 CARL D SILVER PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4913
Practice Address - Country:US
Practice Address - Phone:540-786-7957
Practice Address - Fax:540-548-7401
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230006484183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician