Organization
P. ROMAN BURK DPM PC
Active
Other names
Mountain Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
PHILLIP ROMAN BURK (OWNER)
(208) 855-0701
Entity
Organization
Contact information
Practice address
2667 E. GALA COURT SUITE 125, MERIDIAN, ID 83642
(208) 855-0701
(208) 268-6301
Mailing address
2667 E. GALA COURT SUITE 125, MERIDIAN, ID 83642
(208) 855-0701
(208) 459-8628
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
47034RP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1508365958
—
ID
01
—
2175811
PK
—
Enumeration date
02/12/2018
Last updated
10/07/2020
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