Provider Demographics
NPI:1063024222
Name:BUSH, LAKEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAKEN
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 HARRISON LN
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37379-4832
Mailing Address - Country:US
Mailing Address - Phone:423-332-5124
Mailing Address - Fax:
Practice Address - Street 1:121 HARRISON LN
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-4832
Practice Address - Country:US
Practice Address - Phone:423-332-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000041346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist