Provider Demographics
NPI:1629680624
Name:MARTIN, AMANDA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 JOHNSON ST SE
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:GA
Mailing Address - Zip Code:39842-1523
Mailing Address - Country:US
Mailing Address - Phone:229-995-2126
Mailing Address - Fax:
Practice Address - Street 1:412 JOHNSON ST SE
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:GA
Practice Address - Zip Code:39842-1523
Practice Address - Country:US
Practice Address - Phone:229-995-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist