Healthcare Provider Details

I. General information

NPI: 1366727448
Provider Name (Legal Business Name): AMANDA MARIE GRYCOWSKI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W MURDOCK AVE
OSHKOSH WI
54901-2210
US

IV. Provider business mailing address

315 W MURDOCK AVE
OSHKOSH WI
54901-2210
US

V. Phone/Fax

Practice location:
  • Phone: 920-231-8664
  • Fax: 920-231-8965
Mailing address:
  • Phone: 920-231-8664
  • Fax: 920-231-8965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14579-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: