Healthcare Provider Details

I. General information

NPI: 1194652412
Provider Name (Legal Business Name): BURGESS DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MEDICAL LOOP STE 2
WHITLEY CITY KY
42653-4329
US

IV. Provider business mailing address

PO BOX 309
WHITLEY CITY KY
42653-0309
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JAIME PAUL BALL
Title or Position: SECRETARY
Credential: PHARMD
Phone: 606-376-5043