Provider Demographics
NPI:1205308749
Name:BURGESS, RICKY E
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:E
Last Name:BURGESS
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 1:12515 E 55TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-6234
Mailing Address - Country:US
Mailing Address - Phone:918-493-2727
Mailing Address - Fax:800-375-2729
Practice Address - Street 1:12515 E 55TH ST STE 101
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6234
Practice Address - Country:US
Practice Address - Phone:918-493-2727
Practice Address - Fax:800-375-2729
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15155183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist