=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821631979
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA BLAKNEY BELLMORE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2019
-----------------------------------------------------
Last Update Date | 10/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1022 WALTON WAY
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30901-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-619-2467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3768 BOULDER TRL
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30907-5119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH031754
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------