Provider Demographics
NPI:1033466347
Name:BURT, CHARLES M (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:BURT
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-1129
Mailing Address - Country:US
Mailing Address - Phone:270-298-3278
Mailing Address - Fax:270-298-3290
Practice Address - Street 1:312 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:KY
Practice Address - Zip Code:42347-1129
Practice Address - Country:US
Practice Address - Phone:270-298-3278
Practice Address - Fax:270-298-3290
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist