Provider Demographics
NPI:1629326665
Name:WHITAKER, AMANDA JOHNSON
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOHNSON
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W MANNING ST
Mailing Address - Street 2:
Mailing Address - City:CHESNEE
Mailing Address - State:SC
Mailing Address - Zip Code:29323-1538
Mailing Address - Country:US
Mailing Address - Phone:864-461-3123
Mailing Address - Fax:864-703-2943
Practice Address - Street 1:109 W MANNING ST
Practice Address - Street 2:
Practice Address - City:CHESNEE
Practice Address - State:SC
Practice Address - Zip Code:29323-1538
Practice Address - Country:US
Practice Address - Phone:864-461-3123
Practice Address - Fax:864-703-2943
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist