MEDICARE: SIDNEY WILLIAMS SUSTARICH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RP0013329	WV

General Provider Information

NPI Number	:	1073167862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIDNEY WILLIAMS SUSTARICH

Provider Business Mailing Address
First Line	:	477 W 39TH ST
Second Line	:
City	:	SHADYSIDE
State	:	OH
Zip	:	43947-1158
Country	:	US
Telephone Number	:	334-322-5232
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 3RD ST
Second Line	:
City	:	NEW MARTINSVILLE
State	:	WV
Zip	:	26155-1554
Country	:	US
Telephone Number	:	304-455-1790
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2019
Last Update Date	:	02/08/2023

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Directions to “ SIDNEY WILLIAMS SUSTARICH ” Practice Location

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