MEDICARE: MRS. CHRISTY LEE HAYTACK PHARMD

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	17639	NV
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	12710	NE
3	183500000X	Pharmacist	17639	NV

General Provider Information

NPI Number	:	1285901603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHRISTY LEE HAYTACK PHARMD

Provider Business Mailing Address
First Line	:	12049 ARAGON SPRINGS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-2008
Country	:	US
Telephone Number	:	712-249-1801
Fax Number	:

Provider Business Practice Location Address
First Line	:	4010 W ALI BABA LN STE F
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-1673
Country	:	US
Telephone Number	:	702-483-4230
Fax Number	:	702-483-4611

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

Provider Enumeration Date	:	11/30/2011
Last Update Date	:	01/10/2017

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