Provider Demographics
NPI:1215544861
Name:MILLER, AMANDA RAE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:MILLER
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 1:701 NORTH HIGHWAY 47
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383
Mailing Address - Country:US
Mailing Address - Phone:636-377-2172
Mailing Address - Fax:636-377-2179
Practice Address - Street 1:701 NORTH HIGHWAY 47
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383
Practice Address - Country:US
Practice Address - Phone:636-377-2172
Practice Address - Fax:636-377-2179
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015025682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist