Provider Demographics
NPI:1336553007
Name:WAKIM, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WAKIM
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 1:60 GROTON ST
Mailing Address - Street 2:
Mailing Address - City:PEPPERELL
Mailing Address - State:MA
Mailing Address - Zip Code:01463-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 GROTON ST
Practice Address - Street 2:
Practice Address - City:PEPPERELL
Practice Address - State:MA
Practice Address - Zip Code:01463-1516
Practice Address - Country:US
Practice Address - Phone:978-433-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist