Provider Demographics
NPI:1811014335
Name:BURGARD, MICHAEL CLAYTON (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CLAYTON
Last Name:BURGARD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 E 400TH ST
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62326-1838
Mailing Address - Country:US
Mailing Address - Phone:309-776-4019
Mailing Address - Fax:
Practice Address - Street 1:1600 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2530
Practice Address - Country:US
Practice Address - Phone:309-833-3750
Practice Address - Fax:309-836-8407
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist