Provider Demographics
NPI:1043089683
Name:HURLBURT, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:HURLBURT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-8853
Mailing Address - Country:US
Mailing Address - Phone:308-381-5859
Mailing Address - Fax:
Practice Address - Street 1:3501 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-8853
Practice Address - Country:US
Practice Address - Phone:308-381-5859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist