Provider Demographics
NPI:1144930850
Name:USTIC, SEAN TYRONE (PHARMD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:TYRONE
Last Name:USTIC
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 POINTER LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4630
Mailing Address - Country:US
Mailing Address - Phone:520-705-4255
Mailing Address - Fax:
Practice Address - Street 1:40100 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-5906
Practice Address - Country:US
Practice Address - Phone:863-419-2366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS453861835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS45386OtherSTATE OF FLORIDA PHARMACY LICENSE