Provider Demographics
NPI:1700967551
Name:BURNHAM-MCKINNEY PHARMACY NO 3 LLC
Entity type:Organization
Organization Name:BURNHAM-MCKINNEY PHARMACY NO 3 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPANIER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:228-497-4483
Mailing Address - Street 1:2525 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5247
Mailing Address - Country:US
Mailing Address - Phone:228-497-4483
Mailing Address - Fax:228-497-4490
Practice Address - Street 1:2525 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5247
Practice Address - Country:US
Practice Address - Phone:228-497-4483
Practice Address - Fax:228-497-4490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330248Medicaid