Provider Demographics
NPI:1053696112
Name:HARRIS, AMANDA JOAN (PHARMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOAN
Last Name:HARRIS
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 1:522 TORRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-3216
Mailing Address - Country:US
Mailing Address - Phone:708-868-5669
Mailing Address - Fax:708-868-5694
Practice Address - Street 1:522 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-3216
Practice Address - Country:US
Practice Address - Phone:708-868-5669
Practice Address - Fax:708-868-5694
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist