Basic Information
| Provider Information | |||||||||
| NPI: | 1346411279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURK | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | MCDEED | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURK | ||||||||
| OtherFirstName: | JASON | ||||||||
| OtherMiddleName: | MCDEED | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPH | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 WILFORD HALL LOOP STE 1 | ||||||||
| Address2: | |||||||||
| City: | JBSA LACKLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782365638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102927970 | ||||||||
| FaxNumber: | 2102923880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 WILFORD HALL LOOP BLDG 4554 | ||||||||
| Address2: | |||||||||
| City: | JBSA LACKLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782365638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102927970 | ||||||||
| FaxNumber: | 2102923880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2008 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 36180 | TX | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.