Provider Demographics
NPI:1669076048
Name:HARPER, AMANDA R
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:HARPER
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 1:74 COUNTY ROAD 1713
Mailing Address - Street 2:
Mailing Address - City:BAY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39422-9450
Mailing Address - Country:US
Mailing Address - Phone:601-670-6831
Mailing Address - Fax:
Practice Address - Street 1:1621 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2123
Practice Address - Country:US
Practice Address - Phone:601-649-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-11707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist