Provider Demographics
NPI:1871939231
Name:BURSE, CHARLIE JOE III (DPH)
Entity type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:JOE
Last Name:BURSE
Suffix:III
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-8701
Mailing Address - Country:US
Mailing Address - Phone:901-409-4167
Mailing Address - Fax:
Practice Address - Street 1:1485 WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087
Practice Address - Country:US
Practice Address - Phone:901-409-4167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist