Provider Demographics
NPI:1447851134
Name:BURT, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BURT
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 1:255 S HIGHWAY 55
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-3533
Mailing Address - Country:US
Mailing Address - Phone:435-637-6974
Mailing Address - Fax:435-637-8557
Practice Address - Street 1:255 S HIGHWAY 55
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-3533
Practice Address - Country:US
Practice Address - Phone:435-637-6974
Practice Address - Fax:435-637-8557
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5257032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty