Healthcare Provider Details

I. General information

NPI: 1689346512
Provider Name (Legal Business Name): JACOB WILLIAM BUSH PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W NORTH ST
SPRINGFIELD OH
45504-2607
US

IV. Provider business mailing address

1708 ASCHINGER BLVD
COLUMBUS OH
43212-2694
US

V. Phone/Fax

Practice location:
  • Phone: 937-324-5796
  • Fax:
Mailing address:
  • Phone: 612-226-0780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number125359
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03441089
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: