Provider Demographics
NPI:1467939645
Name:LEWIS, BONNIE KATE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:KATE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 COATES BLUFF DR APT 433
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2849
Mailing Address - Country:US
Mailing Address - Phone:318-450-7255
Mailing Address - Fax:
Practice Address - Street 1:4000 BARKSDALE BLVD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-3902
Practice Address - Country:US
Practice Address - Phone:318-606-6306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist