Provider Demographics
NPI:1679152599
Name:BUSBY, DAMON A (CPHT)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:A
Last Name:BUSBY
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3022
Mailing Address - Country:US
Mailing Address - Phone:131-335-2252
Mailing Address - Fax:
Practice Address - Street 1:23800 ALLEN RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-3374
Practice Address - Country:US
Practice Address - Phone:734-675-4815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303029868183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician