MEDICARE: DR. AMANDA JOY LAKE PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	10534	SC

General Provider Information

NPI Number	:	1265738694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA JOY LAKE PHARMD

Provider Business Mailing Address
First Line	:	219 GLENVILLE DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715-5815
Country	:	US
Telephone Number	:	803-802-4424
Fax Number	:	803-802-4432

Provider Business Practice Location Address
First Line	:	219 GLENVILLE DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715-5815
Country	:	US
Telephone Number	:	803-802-4424
Fax Number	:	803-802-4432

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2011
Last Update Date	:	02/02/2011

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