Provider Demographics
NPI:1992002935
Name:BUSH, KENNETH MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:BUSH
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 1:21000 E 12 MILE RD
Mailing Address - Street 2:STE 124
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1116
Mailing Address - Country:US
Mailing Address - Phone:586-447-5030
Mailing Address - Fax:586-447-5034
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:STE 124
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1116
Practice Address - Country:US
Practice Address - Phone:586-447-5030
Practice Address - Fax:586-447-5034
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030514183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist