Provider Demographics
NPI:1114209897
Name:RANDAZZO, AMANDA K (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:K
Last Name:RANDAZZO
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 1:540 LACROIX WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2858
Mailing Address - Country:US
Mailing Address - Phone:618-281-3876
Mailing Address - Fax:618-632-7228
Practice Address - Street 1:704 CAMBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1964
Practice Address - Country:US
Practice Address - Phone:618-632-6920
Practice Address - Fax:618-632-7228
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-289283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist