Provider Demographics
NPI:1013223841
Name:STAAK, AMANDA LEE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LEE
Last Name:STAAK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 FERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3702
Mailing Address - Country:US
Mailing Address - Phone:203-777-0695
Mailing Address - Fax:
Practice Address - Street 1:325 FERRY ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3702
Practice Address - Country:US
Practice Address - Phone:203-777-0695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0010533183500000X
CA62743183500000X
CO17721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist