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General NPI Number Information
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NPI Number | 1740902675
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Entity Type | Organization
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Legal Business Name | P. ROMAN BURK DPM PC
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Dates
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Enumeration Date | 09/16/2022
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Last Update Date | 09/16/2022
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Provider Practice Location Address
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Address Line | 4605 ENTERPRISE WAY STE: 102
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City | CALDWELL
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State | ID
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Zip | 83605
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Country | US
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Telephone | 208-795-5090
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Fax |
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Provider Business Mailing Address
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Address Line | 2667 E GALA CT STE 125
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City | MERIDIAN
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State | ID
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Zip | 83642-2789
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Country | US
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Telephone | 208-795-5090
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | P. ROMAN BURK
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Credential | DPM
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Telephone | 208-855-0701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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