Healthcare Provider Details

I. General information

NPI: 1043089683
Provider Name (Legal Business Name): MANDY HURLBURT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 S LOCUST ST
GRAND ISLAND NE
68801-8853
US

IV. Provider business mailing address

3501 S LOCUST ST
GRAND ISLAND NE
68801-8853
US

V. Phone/Fax

Practice location:
  • Phone: 308-381-5859
  • Fax:
Mailing address:
  • Phone: 308-381-5859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12372
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: