Healthcare Provider Details

I. General information

NPI: 1134114440
Provider Name (Legal Business Name): AMANDA MARIE DEBRUIN PHARM.D., BCPS, CGP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12901 BRUCE B DOWNS BLVD MDC 13
TAMPA FL
33612-4742
US

IV. Provider business mailing address

12901 BRUCE B DOWNS BLVD MDC 13
TAMPA FL
33612-4742
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-2445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPS38774
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: