1144930850 NPI number — SEAN TYRONE USTIC PHARMD

Table of content: SEAN TYRONE USTIC PHARMD (NPI 1144930850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144930850 NPI number — SEAN TYRONE USTIC PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
USTIC
Provider First Name:
SEAN
Provider Middle Name:
TYRONE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144930850
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
616 POINTER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33809-4630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-705-4255
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40100 HIGHWAY 27
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33837-5906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-419-2366
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P0018X , with the licence number:  PS45386 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PS45386 . This is a "STATE OF FLORIDA PHARMACY LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com