Provider Demographics
NPI:1205115524
Name:DEBUSK, THOMAS IRA III (RPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:IRA
Last Name:DEBUSK
Suffix:III
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 1:561 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-5133
Mailing Address - Country:US
Mailing Address - Phone:276-694-4034
Mailing Address - Fax:
Practice Address - Street 1:140 SOUTH MAIN ST.
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171
Practice Address - Country:US
Practice Address - Phone:297-694-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004380183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202004380OtherCOMMONWEALTH OF VIRGINIA PHARMACIST LICENSE