Healthcare Provider Details

I. General information

NPI: 1194317958
Provider Name (Legal Business Name): ROBERT LEON BURFORD III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W COUNTY LINE RD STE 100
JACKSON MS
39213-9302
US

IV. Provider business mailing address

950 W COUNTY LINE RD STE 100
JACKSON MS
39213-9302
US

V. Phone/Fax

Practice location:
  • Phone: 601-956-1132
  • Fax: 800-874-9908
Mailing address:
  • Phone: 601-956-1132
  • Fax: 800-874-9908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberD-7316
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: