Provider Demographics
NPI:1912286790
Name:KUSTYN, NICOLE MARIE (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:KUSTYN
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 BRITTONFIELD PKWY STE 700
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9249
Mailing Address - Country:US
Mailing Address - Phone:315-472-7504
Mailing Address - Fax:315-634-4419
Practice Address - Street 1:5008 BRITTONFIELD PKWY STE 700
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9249
Practice Address - Country:US
Practice Address - Phone:315-472-7504
Practice Address - Fax:315-634-4419
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20-I055945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist