Provider Demographics
NPI:1619524436
Name:BURSEY, JON SETH
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:SETH
Last Name:BURSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:CROWELL
Mailing Address - State:TX
Mailing Address - Zip Code:79227-0129
Mailing Address - Country:US
Mailing Address - Phone:940-684-1581
Mailing Address - Fax:940-684-1860
Practice Address - Street 1:102 E COMMERCE
Practice Address - Street 2:
Practice Address - City:CROWELL
Practice Address - State:TX
Practice Address - Zip Code:79227
Practice Address - Country:US
Practice Address - Phone:940-684-1581
Practice Address - Fax:940-684-1860
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21308183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist