Provider Demographics
NPI:1114528924
Name:BURGE, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BURGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 KY-15 N
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-7060
Mailing Address - Country:US
Mailing Address - Phone:859-404-5221
Mailing Address - Fax:
Practice Address - Street 1:59 KY 15 N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-4133
Practice Address - Country:US
Practice Address - Phone:859-404-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist