Provider Demographics
NPI:1255997201
Name:LEWIS, DONALD GENE
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:GENE
Last Name:LEWIS
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 1:2001 MILL RUN RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-5623
Mailing Address - Country:US
Mailing Address - Phone:903-952-2929
Mailing Address - Fax:
Practice Address - Street 1:409 W ROYALL BLVD
Practice Address - Street 2:
Practice Address - City:MALAKOFF
Practice Address - State:TX
Practice Address - Zip Code:75148-9499
Practice Address - Country:US
Practice Address - Phone:903-489-1909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154374197OtherTEXAS