Provider Demographics
NPI:1285901603
Name:HAYTACK, CHRISTY LEE (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:CHRISTY
Middle Name:LEE
Last Name:HAYTACK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MS
Other - First Name:CHRISTY
Other - Middle Name:LEE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:12049 ARAGON SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-2008
Mailing Address - Country:US
Mailing Address - Phone:712-249-1801
Mailing Address - Fax:
Practice Address - Street 1:4010 W ALI BABA LN STE F
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1673
Practice Address - Country:US
Practice Address - Phone:702-483-4230
Practice Address - Fax:702-483-4611
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV176391835P0018X, 183500000X
NE127101835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist