Provider Demographics
NPI:1295339141
Name:PETRY, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:PETRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:324 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1102
Mailing Address - Country:US
Mailing Address - Phone:937-492-0700
Mailing Address - Fax:
Practice Address - Street 1:324 4TH AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-1102
Practice Address - Country:US
Practice Address - Phone:937-492-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03233761183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist