Healthcare Provider Details

I. General information

NPI: 1740563030
Provider Name (Legal Business Name): MRS. ALEXANDRA DENISE MOORE LIJEWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 N CASS ST
WABASH IN
46992-1029
US

IV. Provider business mailing address

1309 N CASS ST
WABASH IN
46992-1029
US

V. Phone/Fax

Practice location:
  • Phone: 260-563-1612
  • Fax: 260-563-6053
Mailing address:
  • Phone: 260-563-1612
  • Fax: 260-563-6053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26023286A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: