Provider Demographics
NPI:1245517614
Name:PANCAKE, AMY J (RPH)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:PANCAKE
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 1:5950 STATE BRIDGE RD
Mailing Address - Street 2:T-0749
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-6438
Mailing Address - Country:US
Mailing Address - Phone:678-258-1000
Mailing Address - Fax:678-258-1000
Practice Address - Street 1:5950 STATE BRIDGE RD
Practice Address - Street 2:T-0749
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-6438
Practice Address - Country:US
Practice Address - Phone:678-258-1000
Practice Address - Fax:678-258-1000
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-13
Last Update Date:2011-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH017882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist