Provider Demographics
NPI:1689062671
Name:BURRIS, LESTER II
Entity Type:Individual
Prefix:
First Name:LESTER
Middle Name:
Last Name:BURRIS
Suffix:II
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 1:3029 RIVER BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-9143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2424 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7730
Practice Address - Country:US
Practice Address - Phone:812-287-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024493A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist