Provider Demographics
NPI:1013095678
Name:BURSTYN, MARK RANDY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RANDY
Last Name:BURSTYN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 S BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7512
Mailing Address - Country:US
Mailing Address - Phone:626-447-3591
Mailing Address - Fax:626-447-4679
Practice Address - Street 1:1326 S BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-7512
Practice Address - Country:US
Practice Address - Phone:626-447-3591
Practice Address - Fax:626-447-4679
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 38647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA441560Medicaid
CA0528399OtherNABP NUMBER