Provider Demographics
NPI:1285234153
Name:SMITH, AMY NICHOLE (RPH)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICHOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1862 ALYDAR DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-4678
Mailing Address - Country:US
Mailing Address - Phone:765-427-3212
Mailing Address - Fax:
Practice Address - Street 1:2801 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-6816
Practice Address - Country:US
Practice Address - Phone:765-463-0910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019620A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist