MEDICARE: JESSIE BUSH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS55434	FL

General Provider Information

NPI Number	:	1346797735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIE BUSH

Provider Business Mailing Address
First Line	:	2801 N PONCE DE LEON BLVD
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32084-1648
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 N PONCE DE LEON BLVD
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32084-1648
Country	:	US
Telephone Number	:	904-810-2200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2016
Last Update Date	:	12/21/2020

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Directions to “ JESSIE BUSH ” Practice Location

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