Provider Demographics
NPI:1053867671
Name:DUGAL, AMANDA L (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:L
Last Name:DUGAL
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 1:5841 S MARYLAND AVE
Mailing Address - Street 2:MC0010
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1447
Mailing Address - Country:US
Mailing Address - Phone:773-702-3519
Mailing Address - Fax:773-926-0700
Practice Address - Street 1:5758 S MARYLAND AVE
Practice Address - Street 2:DCAM 1005
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1426
Practice Address - Country:US
Practice Address - Phone:773-702-3519
Practice Address - Fax:773-926-0700
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL05129587183500000X
KS1-14895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1-14895OtherKS PHARMACIST STATE LICENSE
IL051295287OtherIL REGISTERED PHARMACIST LICENSE