Healthcare Provider Details

I. General information

NPI: 1942847686
Provider Name (Legal Business Name): BURGESS DRUG STORE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S. CREEK DR. STE. #122
MONTICELLO KY
42633
US

IV. Provider business mailing address

PO BOX 279
WHITLEY CITY KY
42653
US

V. Phone/Fax

Practice location:
  • Phone: 606-376-5043
  • Fax: 606-376-5466
Mailing address:
  • Phone: 606-376-5043
  • Fax: 606-376-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. JAIME P. BALL
Title or Position: DR./OWNER
Credential: PHARMD
Phone: 606-310-3910