Provider Demographics
NPI:1114628088
Name:REID, AMANDA MAY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAY
Last Name:REID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MAY
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:MANCELONA
Mailing Address - State:MI
Mailing Address - Zip Code:49659-0058
Mailing Address - Country:US
Mailing Address - Phone:231-676-0506
Mailing Address - Fax:
Practice Address - Street 1:902 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-8061
Practice Address - Country:US
Practice Address - Phone:231-258-2081
Practice Address - Fax:231-258-5883
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303035938183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician