Provider Demographics
NPI:1548146210
Name:SMITH, AMANDA NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:SMITH
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 1:25108 CYRILLA BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362-9711
Mailing Address - Country:US
Mailing Address - Phone:218-290-8161
Mailing Address - Fax:
Practice Address - Street 1:200 W 1ST ST
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-1445
Practice Address - Country:US
Practice Address - Phone:320-243-3767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN127071183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist