Provider Demographics
NPI:1649871336
Name:BURNHAM, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8254
Mailing Address - Country:US
Mailing Address - Phone:207-576-1638
Mailing Address - Fax:
Practice Address - Street 1:40 MAIN AVE
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:ME
Practice Address - Zip Code:04345-2176
Practice Address - Country:US
Practice Address - Phone:207-582-3771
Practice Address - Fax:207-582-4089
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist