MEDICARE: QYSHANDRA LYSHEA REXROAT CPHT

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	183700000X	Pharmacy Technician	67020716A	IN

General Provider Information

NPI Number	:	1639802598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QYSHANDRA LYSHEA REXROAT CPHT

Provider Business Mailing Address
First Line	:	2726 ETHEL AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-5160
Country	:	US
Telephone Number	:	463-212-2160
Fax Number	:

Provider Business Practice Location Address
First Line	:	2726 ETHEL AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-5160
Country	:	US
Telephone Number	:	463-212-2160
Fax Number	:

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

Provider Enumeration Date	:	07/07/2022
Last Update Date	:	07/07/2022

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