Provider Demographics
NPI:1366729287
Name:KUSH, MARK T (R PH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:T
Last Name:KUSH
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6841 LONGWORTH DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-1122
Mailing Address - Country:US
Mailing Address - Phone:248-623-0284
Mailing Address - Fax:
Practice Address - Street 1:7110 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2014
Practice Address - Country:US
Practice Address - Phone:248-922-1139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-06
Last Update Date:2011-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024741183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist