Provider Demographics
NPI:1821656075
Name:SERPA, AMAYA (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMAYA
Middle Name:
Last Name:SERPA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SISTER MICHAELA
Other - Middle Name:
Other - Last Name:SERPA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2098 TRUCKERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-7405
Mailing Address - Country:US
Mailing Address - Phone:203-427-7051
Mailing Address - Fax:
Practice Address - Street 1:2325 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:203-427-7051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.00113821835P0018X
MEPR70433183500000X
IDP62641835C0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0206XPharmacy Service ProvidersPharmacistCardiology
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist