Provider Demographics
NPI:1043454069
Name:WILBURN, AMANDA J (PHARMD, CDE)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:WILBURN
Suffix:
Gender:F
Credentials:PHARMD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 COUNTY ROAD 470
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-6862
Mailing Address - Country:US
Mailing Address - Phone:662-223-0300
Mailing Address - Fax:662-286-5533
Practice Address - Street 1:2049 E SHILOH RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-3726
Practice Address - Country:US
Practice Address - Phone:662-286-6914
Practice Address - Fax:662-286-5533
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-09695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist