Provider Demographics
NPI:1629678875
Name:BURKHOLDER, AMANDA SUE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SUE
Last Name:BURKHOLDER
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 1:13511 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-9413
Mailing Address - Country:US
Mailing Address - Phone:419-335-0101
Mailing Address - Fax:
Practice Address - Street 1:1815 SCOTT ST
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-1086
Practice Address - Country:US
Practice Address - Phone:419-599-0170
Practice Address - Fax:419-599-0370
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0332551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist