Healthcare Provider Details

I. General information

NPI: 1326321571
Provider Name (Legal Business Name): AMANDA URBANIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JASON DR
TROY MO
63379-1944
US

IV. Provider business mailing address

676 BETHANY LN
WENTZVILLE MO
63385-6845
US

V. Phone/Fax

Practice location:
  • Phone: 636-462-5901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2010027766-
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: