Provider Demographics
NPI:1649417114
Name:LAI AO, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LAI AO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:LAI AO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:90-20 ELMHURST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:718-651-1177
Mailing Address - Fax:
Practice Address - Street 1:9020 ELMHURST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7936
Practice Address - Country:US
Practice Address - Phone:718-651-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist