Healthcare Provider Details

I. General information

NPI: 1790293579
Provider Name (Legal Business Name): AMANDA DIANE REISBIG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TECHNOLOGY CENTER DR
STOUGHTON MA
02072-4710
US

IV. Provider business mailing address

461 PORTER RD
EAST LONGMEADOW MA
01028-1443
US

V. Phone/Fax

Practice location:
  • Phone: 781-566-5066
  • Fax:
Mailing address:
  • Phone: 413-478-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH239027
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPI162065
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: