Healthcare Provider Details

I. General information

NPI: 1144515461
Provider Name (Legal Business Name): AMANDA NICOLE ECCLESTON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 UNIVERSITY CITY BLVD TARGET PHARMACY T-1081
CHARLOTTE NC
28213-8126
US

IV. Provider business mailing address

8120 UNIVERSITY CITY BLVD TARGET PHARMACY T-1081
CHARLOTTE NC
28213-8126
US

V. Phone/Fax

Practice location:
  • Phone: 704-599-3472
  • Fax: 704-599-3472
Mailing address:
  • Phone: 704-599-3472
  • Fax: 704-599-3472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17939
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: