Provider Demographics
NPI:1972825149
Name:BURGESS, GARY WILLIAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:WILLIAM
Last Name:BURGESS
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 1:1322 AMESBURY AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3238
Mailing Address - Country:US
Mailing Address - Phone:816-781-4805
Mailing Address - Fax:
Practice Address - Street 1:16200 E US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64056-1521
Practice Address - Country:US
Practice Address - Phone:816-257-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist