Provider Demographics
NPI:1669620001
Name:BURDESHAW, BRUCE BROOKSBANK (RPH)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:BROOKSBANK
Last Name:BURDESHAW
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 WHITLOCK AVE SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3033
Mailing Address - Country:US
Mailing Address - Phone:770-427-8155
Mailing Address - Fax:
Practice Address - Street 1:731 WHITLOCK AVE SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-3033
Practice Address - Country:US
Practice Address - Phone:770-427-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA09359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist