Healthcare Provider Details

I. General information

NPI: 1932886355
Provider Name (Legal Business Name): CLIVE BURUCHARA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 NIAGARA LN N STE 100
MAPLE GROVE MN
55369-7588
US

IV. Provider business mailing address

10150 NIAGARA LN N STE 100
MAPLE GROVE MN
55369-7588
US

V. Phone/Fax

Practice location:
  • Phone: 763-220-1316
  • Fax:
Mailing address:
  • Phone: 763-218-7583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number117935
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: