Provider Demographics
NPI:1689212987
Name:TSERMENGAS, AMANDA JANE
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:JANE
Last Name:TSERMENGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16705 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1442
Mailing Address - Country:US
Mailing Address - Phone:734-286-9220
Mailing Address - Fax:
Practice Address - Street 1:16705 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1442
Practice Address - Country:US
Practice Address - Phone:734-286-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist