Provider Demographics
NPI:1699298877
Name:BURCHAM, MARCUS BLAKE (PHARMD)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:BLAKE
Last Name:BURCHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 FRIENDSHIP RD
Mailing Address - Street 2:
Mailing Address - City:ECRU
Mailing Address - State:MS
Mailing Address - Zip Code:38841-9649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:902 S GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6312
Practice Address - Country:US
Practice Address - Phone:662-844-1318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-15058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist