Provider Demographics
NPI:1811016587
Name:WADSTROM, AMY JO (RPH)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:WADSTROM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 17TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-4800
Mailing Address - Country:US
Mailing Address - Phone:515-971-2117
Mailing Address - Fax:515-280-5106
Practice Address - Street 1:3221 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1304
Practice Address - Country:US
Practice Address - Phone:515-246-1390
Practice Address - Fax:515-280-5106
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist