Provider Demographics
NPI:1124639067
Name:MCCULLOUGH, AMANDA (PHARM D, RPH)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-3805
Mailing Address - Country:US
Mailing Address - Phone:216-390-0187
Mailing Address - Fax:
Practice Address - Street 1:12395 MCCRACKEN RD STE H
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2946
Practice Address - Country:US
Practice Address - Phone:216-504-3646
Practice Address - Fax:216-332-0799
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03136135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist