Provider Demographics
NPI:1063793297
Name:CAMPO, AMANDA NICOLE (PHARMD)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:NICOLE
Last Name:CAMPO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:CONDITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:302 UNIVERSITY PL
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-7110
Mailing Address - Country:US
Mailing Address - Phone:580-920-1145
Mailing Address - Fax:
Practice Address - Street 1:302 UNIVERSITY PL
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-7110
Practice Address - Country:US
Practice Address - Phone:580-920-1145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist