Provider Demographics
NPI:1689020596
Name:JOHNSON, AMANDA A (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:A
Other - Last Name:SHEPPARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:302 GREAT TEAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9349
Mailing Address - Country:US
Mailing Address - Phone:303-757-8952
Mailing Address - Fax:
Practice Address - Street 1:302 GREAT TEAYS BLVD
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9349
Practice Address - Country:US
Practice Address - Phone:303-757-8952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0009343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist