Provider Demographics
NPI:1275853939
Name:TA, AMANDA (PHARM D)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TA
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11885 LAMPLIGHTER LN
Mailing Address - Street 2:
Mailing Address - City:OAK HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92344-8691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1380 BARSTOW RD
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-4944
Practice Address - Country:US
Practice Address - Phone:760-252-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51097183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist