MEDICARE: CHRISTINA LOUISE STAYBACK

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	183500000X	Pharmacist	26016035A	IN

General Provider Information

NPI Number	:	1407453301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA LOUISE STAYBACK

Provider Business Mailing Address
First Line	:	5280 E 200 N
Second Line	:
City	:	ANGOLA
State	:	IN
Zip	:	46703-9279
Country	:	US
Telephone Number	:	260-668-1501
Fax Number	:

Provider Business Practice Location Address
First Line	:	2016 N WAYNE ST
Second Line	:
City	:	ANGOLA
State	:	IN
Zip	:	46703-9102
Country	:	US
Telephone Number	:	260-665-7033
Fax Number	:	260-665-6831

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

Provider Enumeration Date	:	10/04/2020
Last Update Date	:	10/04/2020

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Directions to “ CHRISTINA LOUISE STAYBACK ” Practice Location

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