Provider Demographics
NPI:1265730550
Name:BUSHAY, CALVERN RUDOLPH
Entity type:Individual
Prefix:
First Name:CALVERN
Middle Name:RUDOLPH
Last Name:BUSHAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 W DUPONT AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25015-1075
Mailing Address - Country:US
Mailing Address - Phone:304-926-6889
Mailing Address - Fax:304-926-6891
Practice Address - Street 1:3175 W DUPONT AVE
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:WV
Practice Address - Zip Code:25015-1075
Practice Address - Country:US
Practice Address - Phone:304-926-6889
Practice Address - Fax:304-926-6891
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist