1164960688 NPI number — ANDERSON BURRIS INC

Table of content: (NPI 1164960688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164960688 NPI number — ANDERSON BURRIS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDERSON BURRIS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HOPE WELLNESS PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164960688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47421-0366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-546-2502
Provider Business Mailing Address Fax Number:
812-546-2336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
645 HARRISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOPE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47246-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-287-8884
Provider Business Practice Location Address Fax Number:
812-287-8921
Provider Enumeration Date:
02/03/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BURRIS
Authorized Official First Name:
LESTER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
812-546-2502

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 60006601A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2167643 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300002470A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".