Provider Demographics
NPI:1851976880
Name:CLEGG, AMY W (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:W
Last Name:CLEGG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MLK JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-5620
Mailing Address - Country:US
Mailing Address - Phone:770-267-2559
Mailing Address - Fax:770-267-4048
Practice Address - Street 1:150 MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-5620
Practice Address - Country:US
Practice Address - Phone:770-267-2559
Practice Address - Fax:770-267-4048
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist