Provider Demographics
NPI:1437424512
Name:HARDISTY, AMANDA DAWN (CPHT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DAWN
Last Name:HARDISTY
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 W HIGHWAY 52
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-9738
Mailing Address - Country:US
Mailing Address - Phone:208-272-9454
Mailing Address - Fax:208-272-9460
Practice Address - Street 1:640 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9427
Practice Address - Country:US
Practice Address - Phone:208-365-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT-0005101183700000X
IDCT1059183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician