Healthcare Provider Details

I. General information

NPI: 1336769488
Provider Name (Legal Business Name): SHAUN THOMAS LASKY PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2020
Last Update Date: 04/18/2020
Certification Date: 04/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10427 BIG BEND RD
RIVERVIEW FL
33578-7415
US

IV. Provider business mailing address

10427 BIG BEND RD
RIVERVIEW FL
33578-7415
US

V. Phone/Fax

Practice location:
  • Phone: 813-347-5023
  • Fax:
Mailing address:
  • Phone: 813-347-5023
  • Fax: 813-347-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS56524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: