Provider Demographics
NPI:1699374157
Name:MYXTER, TAMARA DAWN
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:DAWN
Last Name:MYXTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5421 LUCKY CLOVER ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-2022
Mailing Address - Country:US
Mailing Address - Phone:702-647-2799
Mailing Address - Fax:702-647-4482
Practice Address - Street 1:7130 N DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4466
Practice Address - Country:US
Practice Address - Phone:702-647-2799
Practice Address - Fax:702-647-4482
Is Sole Proprietor?:No
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101141835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist