Provider Demographics
NPI:1215376876
Name:BASTA, SHERIF
Entity Type:Individual
Prefix:
First Name:SHERIF
Middle Name:
Last Name:BASTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 SAND MINE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-3400
Mailing Address - Country:US
Mailing Address - Phone:863-424-9973
Mailing Address - Fax:
Practice Address - Street 1:2424 SAND MINE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-3400
Practice Address - Country:US
Practice Address - Phone:863-424-9973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS48874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist