Provider Demographics
NPI:1437675063
Name:BRUNSON, MIRANDA BURGESS (PHARMD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:BURGESS
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:LORRAINE
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:324 SADDLEHORN LN
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-3060
Mailing Address - Country:US
Mailing Address - Phone:864-380-9536
Mailing Address - Fax:
Practice Address - Street 1:6414 STATE PARK RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1634
Practice Address - Country:US
Practice Address - Phone:864-834-7936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist