Provider Demographics
NPI:1194030304
Name:BURKHART, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BURKHART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 N SR 89
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-5956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 N SR 89
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5956
Practice Address - Country:US
Practice Address - Phone:928-636-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS012804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist