Basic Information
Provider Information | |||||||||
NPI: | 1598826497 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURKHALTER | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARM.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 HOSPITAL RD | ||||||||
Address2: | FAMILY MEDICINE CLINIC | ||||||||
City: | FORT GORDON | ||||||||
State: | GA | ||||||||
PostalCode: | 309055650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067870025 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 HOSPITAL RD | ||||||||
Address2: | 2ND FLOOR, FAMILY MEDICINE CLINIC | ||||||||
City: | FORT. GORDON | ||||||||
State: | GA | ||||||||
PostalCode: | 309055650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067870025 | ||||||||
FaxNumber: | 7067879356 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2006 | ||||||||
LastUpdateDate: | 10/16/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 008613 | SC | Y |   | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.