MEDICARE: DR. ETHEL O BUBU PHARM.D.,RPH

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	40585	TX
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	26020680A	IN

General Provider Information

NPI Number	:	1568723708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHEL O BUBU PHARM.D.,RPH

Provider Business Mailing Address
First Line	:	2007 CROSBYTON LN
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-8868
Country	:	US
Telephone Number	:	502-418-7872
Fax Number	:	214-235-0903

Provider Business Practice Location Address
First Line	:	2007 CROSBYTON LN
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-8868
Country	:	US
Telephone Number	:	502-418-7872
Fax Number	:	214-235-0903

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

Provider Enumeration Date	:	06/05/2012
Last Update Date	:	06/05/2012

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