Healthcare Provider Details

I. General information

NPI: 1821656075
Provider Name (Legal Business Name): AMAYA SERPA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SISTER MICHAELA SERPA

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

2098 TRUCKERSVILLE RD
POCATELLO ID
83204-7405
US

V. Phone/Fax

Practice location:
  • Phone: 203-427-7051
  • Fax:
Mailing address:
  • Phone: 203-427-7051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPR70433
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPCT.0011382
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code1835C0206X
TaxonomyCardiology Pharmacist
License NumberP6264
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: