Provider Demographics
NPI:1629830922
Name:MIETLICKI, AMANDA JANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:MIETLICKI
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 1:2482 CIDER ST
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482-9504
Mailing Address - Country:US
Mailing Address - Phone:585-991-3976
Mailing Address - Fax:
Practice Address - Street 1:6363 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5855
Practice Address - Country:US
Practice Address - Phone:716-635-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI071169-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist