=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962783787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA BERCEY PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2011
-----------------------------------------------------
Last Update Date | 11/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2050 W COUNTY HIGHWAY 30A # M1-106
-----------------------------------------------------
City | SANTA ROSA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32459-0187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-622-3313
-----------------------------------------------------
Fax | 850-622-3255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 238 N SAND PALM RD FL 32439
-----------------------------------------------------
City | FREEPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32439-3731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-330-1405
-----------------------------------------------------
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 | 019517
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------