Healthcare Provider Details

I. General information

NPI: 1891395448
Provider Name (Legal Business Name): AMANDA HURTT RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2020
Last Update Date: 10/31/2020
Certification Date: 10/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 N MARKET ST STOP 1
WATERLOO IL
62298-1061
US

IV. Provider business mailing address

7024 FOUNTAIN OAK LN
WATERLOO IL
62298-5235
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4088
  • Fax: 618-939-3419
Mailing address:
  • Phone: 618-410-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.290045
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: