Provider Demographics
NPI:1003198318
Name:UPDEGRAFF, AMANDA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:UPDEGRAFF
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 MEXICO LOOP RD E
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-6015
Mailing Address - Country:US
Mailing Address - Phone:636-978-1602
Mailing Address - Fax:
Practice Address - Street 1:1490 MEXICO LOOP RD E
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-6015
Practice Address - Country:US
Practice Address - Phone:636-978-1602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2022-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011024492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist