Provider Demographics
NPI:1891195137
Name:SAMPLE, AMANDA (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:SUE
Other - Last Name:RABIDEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:10580 W USTICK RD
Mailing Address - Street 2:STORE #5184
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5267
Mailing Address - Country:US
Mailing Address - Phone:208-377-3581
Mailing Address - Fax:
Practice Address - Street 1:10580 W USTICK RD
Practice Address - Street 2:STORE #5184
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5267
Practice Address - Country:US
Practice Address - Phone:208-377-3581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7083183500000X
IDCS36244183500000X
NYI059211-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist