Provider Demographics
NPI:1649547241
Name:BURGESS, DANA (RPH)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 FORK RD
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28128-8445
Mailing Address - Country:US
Mailing Address - Phone:704-474-4035
Mailing Address - Fax:
Practice Address - Street 1:552 FORK RD
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:NC
Practice Address - Zip Code:28128-8445
Practice Address - Country:US
Practice Address - Phone:704-474-4035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-27
Last Update Date:2011-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8168183500000X
WAPH00050652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist