Provider Demographics
NPI:1700153806
Name:CSUBAK, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:CSUBAK
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 1:2974 WILDERNESS BLVD E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-9269
Mailing Address - Country:US
Mailing Address - Phone:941-776-3280
Mailing Address - Fax:
Practice Address - Street 1:5945 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-2953
Practice Address - Country:US
Practice Address - Phone:941-722-2884
Practice Address - Fax:941-723-3654
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0023628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist