{
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"FirstLineMailingAddress": "1 OPTUM CIR STE 100",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "EDEN PRAIRIE",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55344-2503",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "800-328-5979",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "8131 W BOSTIAN RD STE A350",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WOODINVILLE",
"PracticeLocationAddressStateName": "WA",
"PracticeLocationAddressPostalCode": "98072-5029",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "855-427-4682",
"PracticeLocationAddressFaxNumber": "877-342-4596",
"EnumerationDate": "09/16/2019",
"LastUpdateDate": "12/04/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BURR",
"AuthorizedOfficialFirstName": "KEVIN",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "712-310-4701",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}