Provider Demographics
NPI:1649321357
Name:FORTKAMP, AMY LOUISE (RPH)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:LOUISE
Last Name:FORTKAMP
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 1:11708 WAYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1449
Mailing Address - Country:US
Mailing Address - Phone:502-245-2350
Mailing Address - Fax:
Practice Address - Street 1:11708 WAYSIDE AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1449
Practice Address - Country:US
Practice Address - Phone:502-245-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist