Healthcare Provider Details

I. General information

NPI: 1679413793
Provider Name (Legal Business Name): MICHAEL TYLER LAUTENBACH RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5349 W PIKE PLAZA RD
INDIANAPOLIS IN
46254-3011
US

IV. Provider business mailing address

5349 W PIKE PLAZA RD
INDIANAPOLIS IN
46254-3011
US

V. Phone/Fax

Practice location:
  • Phone: 317-387-2410
  • Fax: 317-387-2465
Mailing address:
  • Phone: 317-387-2410
  • Fax: 317-387-2465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26031573A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: