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General NPI Number Information
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NPI Number | 1962770297
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Entity Type | Individual
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Provider Name | AMANDA RADTKE PHARM. D.
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Gender | Female
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Dates
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Enumeration Date | 12/01/2011
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Last Update Date | 12/01/2011
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Provider Practice Location Address
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Address Line | 8007 W FLORISSANT AVE
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City | JENNINGS
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State | MO
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Zip | 63136-1400
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Country | US
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Telephone | 314-513-0194
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Fax |
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Provider Business Mailing Address
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Address Line | 901 WELLS AVE APT A
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City | CASEYVILLE
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State | IL
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Zip | 62232-2088
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Country | US
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Telephone | 618-559-5290
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 2009011857
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License Number State | MO
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