Provider Demographics
NPI:1376598946
Name:BOUSHON, MICHAEL C (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
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 1:514 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:PARK FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54552-1325
Mailing Address - Country:US
Mailing Address - Phone:715-744-3788
Mailing Address - Fax:
Practice Address - Street 1:450 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9682
Practice Address - Country:US
Practice Address - Phone:715-588-4267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8877-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist