Healthcare Provider Details

I. General information

NPI: 1720780752
Provider Name (Legal Business Name): DECLAN AIDAN BURKE PHARMACY TECHNICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 SALEM RD
VIRGINIA BEACH VA
23456-1393
US

IV. Provider business mailing address

1808 SALEM RD
VIRGINIA BEACH VA
23456-1393
US

V. Phone/Fax

Practice location:
  • Phone: 757-471-1053
  • Fax: 757-471-3309
Mailing address:
  • Phone: 757-471-1053
  • Fax: 757-471-3309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0230036247
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: