Provider Demographics
NPI:1659620144
Name:SHAW, AMANDA MAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAE
Last Name:SHAW
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 1:1853 DEER CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9381
Mailing Address - Country:US
Mailing Address - Phone:937-408-5330
Mailing Address - Fax:
Practice Address - Street 1:1280 DEMOREST RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-7003
Practice Address - Country:US
Practice Address - Phone:614-279-1962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3329289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist