Provider Demographics
NPI:1396834305
Name:SIMON, AMY LU (PHARM D)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LU
Last Name:SIMON
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:PO BOX 251
Mailing Address - Street 2:
Mailing Address - City:MADDOCK
Mailing Address - State:ND
Mailing Address - Zip Code:58348-0251
Mailing Address - Country:US
Mailing Address - Phone:701-438-2221
Mailing Address - Fax:
Practice Address - Street 1:3883 74TH AVE NE
Practice Address - Street 2:
Practice Address - City:FT.TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-1612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist