Provider Demographics
NPI:1922589332
Name:HAVERSTICK, REBECCA LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:HAVERSTICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:MADSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1550 E COUNTY LINE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-0990
Mailing Address - Country:US
Mailing Address - Phone:317-534-6258
Mailing Address - Fax:
Practice Address - Street 1:1550 E COUNTY LINE RD STE 150
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0990
Practice Address - Country:US
Practice Address - Phone:317-534-6258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024885A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26024885AOtherPHARMACIST LICENSE