Provider Demographics
NPI:1053901066
Name:BURKETT, KIPLAND JAY (RPH)
Entity type:Individual
Prefix:MR
First Name:KIPLAND
Middle Name:JAY
Last Name:BURKETT
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 1:1366 S 350 E
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173-9561
Mailing Address - Country:US
Mailing Address - Phone:765-561-5467
Mailing Address - Fax:765-932-3824
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173-1694
Practice Address - Country:US
Practice Address - Phone:765-932-3328
Practice Address - Fax:765-932-3824
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-23
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014474A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist