Healthcare Provider Details

I. General information

NPI: 1245581255
Provider Name (Legal Business Name): DOMONIQUE VAN BUREN PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 03/04/2021
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E RIVER PL
JACKSON MS
39202-3486
US

IV. Provider business mailing address

805 E RIVER PL
JACKSON MS
39202-3486
US

V. Phone/Fax

Practice location:
  • Phone: 601-500-7660
  • Fax:
Mailing address:
  • Phone: 601-500-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPST.020307
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberT-15181
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: