Provider Demographics
NPI:1720690290
Name:KUSTOV, SERGEY DMITRIYEVICH (PHARMD)
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:DMITRIYEVICH
Last Name:KUSTOV
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 1:10905 DELIBAN ST
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-1451
Mailing Address - Country:US
Mailing Address - Phone:323-352-4440
Mailing Address - Fax:
Practice Address - Street 1:10905 DELIBAN ST
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042-1451
Practice Address - Country:US
Practice Address - Phone:323-352-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program