Provider Demographics
NPI:1326495896
Name:NOVAK, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NOVAK
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 1:375 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-2248
Mailing Address - Country:US
Mailing Address - Phone:847-622-1530
Mailing Address - Fax:847-622-1617
Practice Address - Street 1:375 RANDALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-2248
Practice Address - Country:US
Practice Address - Phone:847-622-1530
Practice Address - Fax:847-622-1617
Is Sole Proprietor?:No
Enumeration Date:2016-05-15
Last Update Date:2016-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist