Provider Demographics
NPI:1811570773
Name:GARDNER, AMY L
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:GARDNER
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 1:2723 101ST ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-2006
Mailing Address - Country:US
Mailing Address - Phone:141-929-7285
Mailing Address - Fax:
Practice Address - Street 1:5033 SUDER AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43611-1487
Practice Address - Country:US
Practice Address - Phone:419-729-9934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09210909183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician