Provider Demographics
NPI:1265082705
Name:BURDETTE, MIKAYLA NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:NICOLE
Last Name:BURDETTE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:NICOLE
Other - Last Name:WICKLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:48 THISTLE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:LINDSIDE
Mailing Address - State:WV
Mailing Address - Zip Code:24951-7035
Mailing Address - Country:US
Mailing Address - Phone:304-646-8987
Mailing Address - Fax:
Practice Address - Street 1:323 S WALKER ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2756
Practice Address - Country:US
Practice Address - Phone:304-431-4967
Practice Address - Fax:304-431-5405
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0011743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0011743OtherPHARMACIST