Provider Demographics
NPI:1154066041
Name:DETORE, AMANDA MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MARIE
Last Name:DETORE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 MOUNT HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-1645
Mailing Address - Country:US
Mailing Address - Phone:973-989-7984
Mailing Address - Fax:
Practice Address - Street 1:381 MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-1645
Practice Address - Country:US
Practice Address - Phone:973-989-7984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04241200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
28RI04241200OtherLICENSE NUMBER