Provider Demographics
NPI:1578105763
Name:HART, AMY MICHELE (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELE
Last Name:HART
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MICHELE
Other - Last Name:SAMPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:KY
Mailing Address - Zip Code:42409-0267
Mailing Address - Country:US
Mailing Address - Phone:270-635-5270
Mailing Address - Fax:
Practice Address - Street 1:127 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1268
Practice Address - Country:US
Practice Address - Phone:270-667-2049
Practice Address - Fax:270-667-7230
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist