Healthcare Provider Details

I. General information

NPI: 1457985921
Provider Name (Legal Business Name): JENNIE BURDETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WASHINGTON BLVD
BELPRE OH
45714-2432
US

IV. Provider business mailing address

201 WASHINGTON BLVD
BELPRE OH
45714-2432
US

V. Phone/Fax

Practice location:
  • Phone: 740-423-4894
  • Fax:
Mailing address:
  • Phone: 740-423-4894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03439263
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: