Provider Demographics
NPI:1902980238
Name:CORY, AMY LOUISE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LOUISE
Last Name:CORY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21386 KLAR JO RD
Mailing Address - Street 2:
Mailing Address - City:CLITHERALL
Mailing Address - State:MN
Mailing Address - Zip Code:56524-9500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:BATTLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:56515-0538
Practice Address - Country:US
Practice Address - Phone:218-864-5261
Practice Address - Fax:218-864-8178
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116119-7183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116119-7OtherPHARMACY LICENSE