Provider Demographics
NPI:1982372298
Name:BURDGE, MARY CATHERINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:BURDGE
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 1:12700 CHARLES FARM CIR APT 203
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-3696
Mailing Address - Country:US
Mailing Address - Phone:615-943-3000
Mailing Address - Fax:
Practice Address - Street 1:7338 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3722
Practice Address - Country:US
Practice Address - Phone:502-937-3747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022256183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist