Provider Demographics
NPI:1346575503
Name:WEGENKA, AMANDA LEA (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEA
Last Name:WEGENKA
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 1:1836 SOUTH AVE # H01-005
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:1900 SOUTH AVE
Practice Address - Street 2:H01-005
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5467
Practice Address - Country:US
Practice Address - Phone:608-775-3701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119551183500000X
IA20886183500000X
WI15643-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist