MEDICARE: BURGIE DRUG STORE LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	348	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2094801	OTHER		PK

General Provider Information

NPI Number	:	1871504449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURGIE DRUG STORE LLC

Provider Business Mailing Address
First Line	:	1000 W G ST
Second Line	:
City	:	ELIZABETHTON
State	:	TN
Zip	:	37643-2959
Country	:	US
Telephone Number	:	423-542-4622
Fax Number	:	423-542-2564

Provider Business Practice Location Address
First Line	:	1000 W G ST
Second Line	:
City	:	ELIZABETHTON
State	:	TN
Zip	:	37643-2959
Country	:	US
Telephone Number	:	423-542-4622
Fax Number	:	423-542-2564

Authorized Official
Title or Position	:	OWNER
Name	:	LARRY PROFFITT
Credential	:	DPH
Telephone Number	:	423-542-4622

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	08/16/2019

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Directions to “BURGIE DRUG STORE LLC ” Practice Location

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