Provider Demographics
NPI:1558966580
Name:LACKEY, AMANDA SUSAN (RPH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUSAN
Last Name:LACKEY
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 1:1010 INDIANAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-1456
Mailing Address - Country:US
Mailing Address - Phone:765-653-9020
Mailing Address - Fax:
Practice Address - Street 1:1010 INDIANAPOLIS RD
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-1456
Practice Address - Country:US
Practice Address - Phone:765-653-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018252A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26018252AOtherINDIANA BOARD OF PHARMACY