Provider Demographics
NPI:1689243859
Name:WILLIAMS, DUSTIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:WILLIAMS
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 1:18115 TUCKAWAY LN
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-8611
Mailing Address - Country:US
Mailing Address - Phone:352-455-4809
Mailing Address - Fax:
Practice Address - Street 1:2521 13TH ST STE A
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4103
Practice Address - Country:US
Practice Address - Phone:407-892-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62994183500000X
FLPSI37606390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program