Provider Demographics
NPI:1417388281
Name:WALKS OVER ICE, AMBER VICTORIA (RPH)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:VICTORIA
Last Name:WALKS OVER ICE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:CROW AGENCY
Mailing Address - State:MT
Mailing Address - Zip Code:59022-0000
Mailing Address - Country:US
Mailing Address - Phone:406-638-3578
Mailing Address - Fax:406-638-3326
Practice Address - Street 1:1 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022-0000
Practice Address - Country:US
Practice Address - Phone:406-638-3578
Practice Address - Fax:406-638-3326
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20988183500000X
MTPHA-PHA-LIC-209881835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist