Healthcare Provider Details

I. General information

NPI: 1952433872
Provider Name (Legal Business Name): AMANAD DIVINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MAGNOLIA SOUTH
LINCOLN AL
35096
US

IV. Provider business mailing address

1103 PINEVIEW AVE
GLENCOE AL
35905-7204
US

V. Phone/Fax

Practice location:
  • Phone: 205-763-7759
  • Fax: 205-763-2131
Mailing address:
  • Phone: 256-492-9193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14604
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: