Provider Demographics
NPI:1619431392
Name:WILLIS, LYNDA MARIE (CPHT)
Entity Type:Individual
Prefix:MRS
First Name:LYNDA
Middle Name:MARIE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 PINEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-6505
Mailing Address - Country:US
Mailing Address - Phone:817-723-3294
Mailing Address - Fax:
Practice Address - Street 1:608 PINEVIEW LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-6505
Practice Address - Country:US
Practice Address - Phone:817-723-3294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105276183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician