Healthcare Provider Details

I. General information

NPI: 1134371370
Provider Name (Legal Business Name): JOHN MICHAEL BOUSUM PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S MOORE AVE
CLAREMORE OK
74017-5047
US

IV. Provider business mailing address

101 S MOORE AVE
CLAREMORE OK
74017-5047
US

V. Phone/Fax

Practice location:
  • Phone: 918-342-6648
  • Fax: 918-342-6330
Mailing address:
  • Phone: 918-342-6648
  • Fax: 918-342-6330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14372
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: