Provider Demographics
NPI:1124346069
Name:MOON, AMANDA SMITH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:SMITH
Last Name:MOON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 LOGANVILLE HWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BETHLEHEM
Mailing Address - State:GA
Mailing Address - Zip Code:30620-2144
Mailing Address - Country:US
Mailing Address - Phone:678-975-3061
Mailing Address - Fax:678-975-6031
Practice Address - Street 1:916 LOGANVILLE HWY
Practice Address - Street 2:SUITE 400
Practice Address - City:BETHLEHEM
Practice Address - State:GA
Practice Address - Zip Code:30620-2144
Practice Address - Country:US
Practice Address - Phone:678-975-3061
Practice Address - Fax:678-975-6031
Is Sole Proprietor?:No
Enumeration Date:2010-05-16
Last Update Date:2010-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist