Provider Demographics
NPI:1306138987
Name:BURKE, JENNIFER PROUDMAN (RPH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PROUDMAN
Last Name:BURKE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NEW HARTFORD RD
Mailing Address - Street 2:BOX 10
Mailing Address - City:WINSTED
Mailing Address - State:CT
Mailing Address - Zip Code:06098-3373
Mailing Address - Country:US
Mailing Address - Phone:860-379-5436
Mailing Address - Fax:860-379-1971
Practice Address - Street 1:200 NEW HARTFORD RD
Practice Address - Street 2:BOX 10
Practice Address - City:WINSTED
Practice Address - State:CT
Practice Address - Zip Code:06098-3373
Practice Address - Country:US
Practice Address - Phone:860-379-5436
Practice Address - Fax:860-379-1971
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist