Provider Demographics
NPI:1154800613
Name:BURKE, PEYTON CECILIA
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:CECILIA
Last Name:BURKE
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 1:763 E 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2331
Mailing Address - Country:US
Mailing Address - Phone:708-339-0453
Mailing Address - Fax:
Practice Address - Street 1:763 E 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473
Practice Address - Country:US
Practice Address - Phone:708-339-0453
Practice Address - Fax:708-339-1554
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027824A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist