Provider Demographics
NPI:1992898910
Name:BUSHARD PHARMACY INC
Entity type:Organization
Organization Name:BUSHARD PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:949-494-1059
Mailing Address - Street 1:244 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651
Mailing Address - Country:US
Mailing Address - Phone:949-494-1059
Mailing Address - Fax:949-494-8807
Practice Address - Street 1:244 FOREST AVE
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651
Practice Address - Country:US
Practice Address - Phone:949-494-1059
Practice Address - Fax:949-494-8807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY34521183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0507612OtherNABP
CAPHA185380Medicaid
CAPHA185380Medicaid