MEDICARE: MS. LISA A BURDICK RPH

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	42833	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	42833	OTHER	NY	NY STATE LICENSE

General Provider Information

NPI Number	:	1588845580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA A BURDICK RPH

Provider Business Mailing Address
First Line	:	84 VALLEY DR
Second Line	:
City	:	WEST SAND LAKE
State	:	NY
Zip	:	12196-1739
Country	:	US
Telephone Number	:	518-674-1309
Fax Number	:

Provider Business Practice Location Address
First Line	:	84 VALLEY DR
Second Line	:
City	:	WEST SAND LAKE
State	:	NY
Zip	:	12196-1739
Country	:	US
Telephone Number	:	518-674-1309
Fax Number	:

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

Provider Enumeration Date	:	11/18/2007
Last Update Date	:	11/18/2007

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