Provider Demographics
NPI:1205417037
Name:MACTAVISH, CHRISTIAN LYLE ANDREW
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:LYLE ANDREW
Last Name:MACTAVISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W PARKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-5405
Mailing Address - Country:US
Mailing Address - Phone:281-996-9971
Mailing Address - Fax:
Practice Address - Street 1:701 W PARKWOOD AVE
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-5405
Practice Address - Country:US
Practice Address - Phone:281-996-9971
Practice Address - Fax:281-996-9980
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310666183500000X, 183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacist