Provider Demographics
NPI:1992235378
Name:BURGESS, MARTI LEA (RPH)
Entity type:Individual
Prefix:
First Name:MARTI
Middle Name:LEA
Last Name:BURGESS
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 1:322 N INGLESIDE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-2924
Mailing Address - Country:US
Mailing Address - Phone:251-689-6551
Mailing Address - Fax:
Practice Address - Street 1:2570 GOVERNMENT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-1614
Practice Address - Country:US
Practice Address - Phone:251-586-6481
Practice Address - Fax:251-586-6482
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL12450OtherSTATE LICENSE