=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649875238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGIE SIVIS RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2020
-----------------------------------------------------
Last Update Date | 12/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 E MARKET ST
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-362-1139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 E MARKET ST
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26018791A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------