Provider Demographics
NPI:1912614223
Name:RUSTAMOVA, SITORA
Entity Type:Individual
Prefix:
First Name:SITORA
Middle Name:
Last Name:RUSTAMOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 SILVERTON LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1796
Mailing Address - Country:US
Mailing Address - Phone:502-202-0527
Mailing Address - Fax:
Practice Address - Street 1:703 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-9582
Practice Address - Country:US
Practice Address - Phone:812-427-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030042A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist