Provider Demographics
NPI:1982317046
Name:DAVIS, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DAVIS
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 1:2323 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-3439
Mailing Address - Country:US
Mailing Address - Phone:440-992-3000
Mailing Address - Fax:440-992-3300
Practice Address - Street 1:2323 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3439
Practice Address - Country:US
Practice Address - Phone:440-992-3000
Practice Address - Fax:440-992-3300
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03127550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist