Provider Demographics
NPI:1043814114
Name:BUSLOVA, YELENA
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:BUSLOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8443 GRAND PRIX LN
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-2735
Mailing Address - Country:US
Mailing Address - Phone:561-573-9623
Mailing Address - Fax:
Practice Address - Street 1:12750 S MILITARY TRL
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-6139
Practice Address - Country:US
Practice Address - Phone:561-637-3695
Practice Address - Fax:561-637-7354
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist