Provider Demographics
NPI:1801473525
Name:BURLESON, MONICA (PHARMD)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:BURLESON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12999 SE 169TH AVE APT 150
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-8722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12999 SE 169TH AVE APT 150
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-8722
Practice Address - Country:US
Practice Address - Phone:864-594-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9693183500000X
ORRPH0016419183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist