Provider Demographics
NPI:1861862310
Name:HENDERSON, AMANDA C (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:HENDERSON
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 1:104 SUNSET CIR
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51576-5043
Mailing Address - Country:US
Mailing Address - Phone:712-309-1664
Mailing Address - Fax:
Practice Address - Street 1:104 SUNSET CIR
Practice Address - Street 2:
Practice Address - City:UNDERWOOD
Practice Address - State:IA
Practice Address - Zip Code:51576-5043
Practice Address - Country:US
Practice Address - Phone:712-309-1664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-27
Last Update Date:2015-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist