Provider Demographics
NPI:1548661705
Name:BUSH, DIANE (RPH)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 DEL PRADO BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-5616
Mailing Address - Country:US
Mailing Address - Phone:239-424-3157
Mailing Address - Fax:239-424-4087
Practice Address - Street 1:708 DEL PRADO BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5616
Practice Address - Country:US
Practice Address - Phone:239-424-3157
Practice Address - Fax:239-424-4087
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34161183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist