Provider Demographics
NPI:1437428695
Name:VASTAG, LYNETTE
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:VASTAG
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 1:7308 OAK RUN LN
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-4550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1224 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2207
Practice Address - Country:US
Practice Address - Phone:941-953-9804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist