Provider Demographics
NPI:1801309935
Name:BURKE, THOMAS EDWARD
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:BURKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351-3249
Mailing Address - Country:US
Mailing Address - Phone:860-376-0132
Mailing Address - Fax:860-376-0413
Practice Address - Street 1:180 RIVER RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:CT
Practice Address - Zip Code:06351-3249
Practice Address - Country:US
Practice Address - Phone:860-376-0132
Practice Address - Fax:860-376-0413
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-11
Last Update Date:2017-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist