Provider Demographics
NPI:1184932733
Name:SIDDON, AMANDA (PHARMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SIDDON
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 1:955 SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05743-9245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1134 WICKER ST
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-3103
Practice Address - Country:US
Practice Address - Phone:518-585-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20055106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist