Healthcare Provider Details

I. General information

NPI: 1053701805
Provider Name (Legal Business Name): AMANDA DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9901 YORK RD
COCKEYSVILLE MD
21030-3407
US

IV. Provider business mailing address

9901 YORK RD
COCKEYSVILLE MD
21030-3407
US

V. Phone/Fax

Practice location:
  • Phone: 410-683-6517
  • Fax: 410-616-2170
Mailing address:
  • Phone: 410-683-6517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT05626
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: