MEDICARE: MR. JACK C TESTASECCA RPH

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	11942	FL

General Provider Information

NPI Number	:	1437372588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK C TESTASECCA RPH

Provider Business Mailing Address
First Line	:	2205 MISTY RIDGE LN
Second Line	:
City	:	VALRICO
State	:	FL
Zip	:	33594-5537
Country	:	US
Telephone Number	:	813-654-5141
Fax Number	:

Provider Business Practice Location Address
First Line	:	1615 SUN CITY CENTER PLZ
Second Line	:
City	:	SUN CITY CENTER
State	:	FL
Zip	:	33573-5385
Country	:	US
Telephone Number	:	813-634-1729
Fax Number	:	813-642-0421

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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