Healthcare Provider Details

I. General information

NPI: 1477946531
Provider Name (Legal Business Name): AMBER LADAK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

66 TIBURON TRL
AUGUSTA GA
30907-3584
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6079
  • Fax:
Mailing address:
  • Phone: 208-807-0648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH028338
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number2013037634
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: