Provider Demographics
NPI:1942804869
Name:BURNETT, ROBERT R
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:R
Last Name:BURNETT
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 1:2486 SHILDMYER RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1000
Mailing Address - Country:US
Mailing Address - Phone:176-538-4415
Mailing Address - Fax:
Practice Address - Street 1:2486 SHILDMYER RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1000
Practice Address - Country:US
Practice Address - Phone:176-538-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013276A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26013276AMedicaid