Provider Demographics
NPI:1528398302
Name:FABUSUYI, BRIDGET
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:FABUSUYI
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 1:18234 BONHAM OAKS CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2298
Mailing Address - Country:US
Mailing Address - Phone:832-372-0225
Mailing Address - Fax:
Practice Address - Street 1:3403 MANGUM RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-7415
Practice Address - Country:US
Practice Address - Phone:713-683-8125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist