Provider Demographics
NPI:1063782480
Name:BURNS, MARLEY
Entity type:Individual
Prefix:
First Name:MARLEY
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 BURNS RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MS
Mailing Address - Zip Code:39365-8236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1005 W BEACON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-3203
Practice Address - Country:US
Practice Address - Phone:601-389-1119
Practice Address - Fax:601-389-9902
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-02
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-11695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist