Provider Demographics
NPI:1003858218
Name:BOUSHON, BRUCE (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:BOUSHON
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 1:142 E ST HWY 260
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4948
Mailing Address - Country:US
Mailing Address - Phone:928-474-7039
Mailing Address - Fax:928-474-3415
Practice Address - Street 1:142 E ST HWY 260
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4948
Practice Address - Country:US
Practice Address - Phone:928-474-7039
Practice Address - Fax:928-474-3415
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12756183500000X
AZS021084183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist