MEDICARE: MRS. LYNDA MARIE WILLIS CPHT

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	183700000X	Pharmacy Technician	105276	TX

General Provider Information

NPI Number	:	1619431392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYNDA MARIE WILLIS CPHT

Provider Business Mailing Address
First Line	:	608 PINEVIEW LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-6505
Country	:	US
Telephone Number	:	817-723-3294
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 PINEVIEW LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-6505
Country	:	US
Telephone Number	:	817-723-3294
Fax Number	:

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

Provider Enumeration Date	:	01/26/2019
Last Update Date	:	01/26/2019

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