Provider Demographics
NPI:1316623929
Name:MUSTAIN, KEVIN C
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:MUSTAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 SE 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-1669
Mailing Address - Country:US
Mailing Address - Phone:954-240-0556
Mailing Address - Fax:
Practice Address - Street 1:1451 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-0041
Practice Address - Country:US
Practice Address - Phone:352-751-8263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS650501835E0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835E0208XPharmacy Service ProvidersPharmacistEmergency Medicine