Healthcare Provider Details

I. General information

NPI: 1922325570
Provider Name (Legal Business Name): AMANDA TANNER ROBERSON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 04/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 INDUSTRIAL BLVD SUITE A
HAWKINSVILLE GA
31036-2106
US

IV. Provider business mailing address

PO BOX 997
HAWKINSVILLE GA
31036-0997
US

V. Phone/Fax

Practice location:
  • Phone: 478-783-1515
  • Fax: 478-783-1404
Mailing address:
  • Phone: 478-783-1515
  • Fax: 478-783-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number018031
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: