Provider Demographics
NPI:1437372588
Name:TESTASECCA, JACK C (RPH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:C
Last Name:TESTASECCA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 MISTY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-5537
Mailing Address - Country:US
Mailing Address - Phone:813-654-5141
Mailing Address - Fax:
Practice Address - Street 1:1615 SUN CITY CENTER PLZ
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5385
Practice Address - Country:US
Practice Address - Phone:813-634-1729
Practice Address - Fax:813-642-0421
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist