Provider Demographics
NPI:1912519745
Name:PAYNE, BURGANDY ANN
Entity Type:Individual
Prefix:
First Name:BURGANDY
Middle Name:ANN
Last Name:PAYNE
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 1:138 PAYNE RD
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:TN
Mailing Address - Zip Code:37325-7027
Mailing Address - Country:US
Mailing Address - Phone:423-715-7592
Mailing Address - Fax:
Practice Address - Street 1:430 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2540
Practice Address - Country:US
Practice Address - Phone:706-695-0444
Practice Address - Fax:706-517-5157
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0321541835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist