Provider Demographics
NPI:1023419785
Name:DOMINGUEZ, AMANDA SIMS (PHARM D)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:SIMS
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4974 HIGHWAY 3276 STE B
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-9335
Mailing Address - Country:US
Mailing Address - Phone:318-775-4371
Mailing Address - Fax:318-775-7369
Practice Address - Street 1:4974 HIGHWAY 3276 STE B
Practice Address - Street 2:
Practice Address - City:STONEWALL
Practice Address - State:LA
Practice Address - Zip Code:71078-9335
Practice Address - Country:US
Practice Address - Phone:318-775-4371
Practice Address - Fax:318-775-7369
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist