Provider Demographics
NPI:1306423868
Name:LEWIS, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 FRALEY DR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-8886
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1179
Practice Address - Country:US
Practice Address - Phone:606-783-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019902183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist