Provider Demographics
NPI:1073143061
Name:BUSBY, NICOLE ANNETTE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNETTE
Last Name:BUSBY
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 1:301 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3725
Mailing Address - Country:US
Mailing Address - Phone:770-954-4375
Mailing Address - Fax:770-954-4734
Practice Address - Street 1:301 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3725
Practice Address - Country:US
Practice Address - Phone:770-954-4375
Practice Address - Fax:770-954-4374
Is Sole Proprietor?:No
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0205411835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist