Healthcare Provider Details

I. General information

NPI: 1871252965
Provider Name (Legal Business Name): SEAN MOLISKE CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 08/31/2024
Certification Date: 08/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 HORIZON LAKE DR STE 101
MEMPHIS TN
38133-8119
US

IV. Provider business mailing address

6835 GALLOP CV
CORDOVA TN
38018-8861
US

V. Phone/Fax

Practice location:
  • Phone: 888-362-5272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA61151042
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049195192
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number66664
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: