Provider Demographics
NPI:1790398998
Name:SOUROUR, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SOUROUR
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 1:1303 SAINT GEORGES AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-3925
Mailing Address - Country:US
Mailing Address - Phone:732-827-2904
Mailing Address - Fax:
Practice Address - Street 1:1303 SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:COLONIA
Practice Address - State:NJ
Practice Address - Zip Code:07067-3925
Practice Address - Country:US
Practice Address - Phone:732-827-2904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03833400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist