Provider Demographics
NPI:1700998614
Name:BURTIS DRUG, INC.
Entity Type:Organization
Organization Name:BURTIS DRUG, INC.
Other - Org Name:GIBSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:BURTIS
Authorized Official - Suffix:SR
Authorized Official - Credentials:PHA
Authorized Official - Phone:972-579-0511
Mailing Address - Street 1:815 N O CONNOR RD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-4510
Mailing Address - Country:US
Mailing Address - Phone:972-579-0511
Mailing Address - Fax:
Practice Address - Street 1:815 N O CONNOR RD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-4510
Practice Address - Country:US
Practice Address - Phone:972-579-0511
Practice Address - Fax:972-579-0512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11854333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4545565OtherOTHER ID NUMBER-COMMERCIAL NUMBER