Provider Demographics
NPI:1740889179
Name:WHITAKER, HAILEY AMANDA (PHARMD)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:AMANDA
Last Name:WHITAKER
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 1:4407 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-1727
Mailing Address - Country:US
Mailing Address - Phone:913-558-0592
Mailing Address - Fax:
Practice Address - Street 1:4900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-8658
Practice Address - Country:US
Practice Address - Phone:505-327-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00009366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist