Provider Demographics
NPI:1942661129
Name:KEITH, AMANDA CAROL (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CAROL
Last Name:KEITH
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 1:3710 N STATE LINE AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1934
Mailing Address - Country:US
Mailing Address - Phone:870-773-5521
Mailing Address - Fax:870-774-8426
Practice Address - Street 1:3710 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1934
Practice Address - Country:US
Practice Address - Phone:870-773-5521
Practice Address - Fax:870-774-8426
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD11964183500000X
TX51595183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist