Provider Demographics
NPI:1639766561
Name:BURGESS, JOHN S (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
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 1:720 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-3313
Mailing Address - Country:US
Mailing Address - Phone:269-686-1418
Mailing Address - Fax:269-684-1457
Practice Address - Street 1:720 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3313
Practice Address - Country:US
Practice Address - Phone:269-684-1418
Practice Address - Fax:269-684-1457
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist