Provider Demographics
NPI:1922552108
Name:ISSA, JUSTIN ISAAC
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ISAAC
Last Name:ISSA
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 1:692 SW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1835
Mailing Address - Country:US
Mailing Address - Phone:772-879-0522
Mailing Address - Fax:
Practice Address - Street 1:692 SW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1835
Practice Address - Country:US
Practice Address - Phone:772-879-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist