MEDICARE: BURGESS DRUG STORE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	1244	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1809764	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1043350069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURGESS DRUG STORE INC

Provider Business Mailing Address
First Line	:	PO BOX 309
Second Line	:
City	:	WHITLEY CITY
State	:	KY
Zip	:	42653-0309
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 MEDICAL LOOP
Second Line	:
City	:	WHITLEY CITY
State	:	KY
Zip	:	42653-0309
Country	:	US
Telephone Number	:	606-376-5043
Fax Number	:	606-376-5466

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES BALL
Credential	:	RPH
Telephone Number	:	606-376-5043

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	09/13/2007

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Directions to “BURGESS DRUG STORE INC ” Practice Location

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