Provider Demographics
NPI:1275924953
Name:CRAKE, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5610 PINEY LANE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-4042
Mailing Address - Country:US
Mailing Address - Phone:813-960-2608
Mailing Address - Fax:
Practice Address - Street 1:1040 DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-3004
Practice Address - Country:US
Practice Address - Phone:813-435-2934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist