Provider Demographics
NPI:1073167862
Name:SUSTARICH, SIDNEY WILLIAMS
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:WILLIAMS
Last Name:SUSTARICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIDNEY
Other - Middle Name:REBECCA
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:477 W 39TH ST
Mailing Address - Street 2:
Mailing Address - City:SHADYSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:43947-1158
Mailing Address - Country:US
Mailing Address - Phone:334-322-5232
Mailing Address - Fax:
Practice Address - Street 1:1021 3RD ST
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1554
Practice Address - Country:US
Practice Address - Phone:304-455-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0013329183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist