Provider Demographics
NPI:1528409141
Name:BURGESS, LARRY MAURICE (RPH)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:MAURICE
Last Name:BURGESS
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 1:245 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-7054
Mailing Address - Country:US
Mailing Address - Phone:863-273-0871
Mailing Address - Fax:
Practice Address - Street 1:245 S LAKE DR
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-7054
Practice Address - Country:US
Practice Address - Phone:863-273-0871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23032183500000X
FLPU 3512183500000X
NC08337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist