MEDICARE: JOHN TIMOTHY BOURKE JR. RP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	4787	NE

General Provider Information

NPI Number	:	1194830653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN TIMOTHY BOURKE JR. RP

Provider Business Mailing Address
First Line	:	PO BOX 111609
Second Line	:	2915 GRANT STREET
City	:	OMAHA
State	:	NE
Zip	:	68111-5609
Country	:	US
Telephone Number	:	402-451-3553
Fax Number	:	402-453-2061

Provider Business Practice Location Address
First Line	:	2915 GRANT ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68111-3863
Country	:	US
Telephone Number	:	402-451-3553
Fax Number	:	402-453-2061

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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