Provider Demographics
NPI:1902181795
Name:DAVIS, AMANDA ROSE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ROSE
Last Name:DAVIS
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 1:2609 SAGE LANE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711
Mailing Address - Country:US
Mailing Address - Phone:217-415-3122
Mailing Address - Fax:
Practice Address - Street 1:2500 KOKE MILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711
Practice Address - Country:US
Practice Address - Phone:217-726-0979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292823183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist