Provider Demographics
NPI:1891395448
Name:HURTT, AMANDA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:HURTT
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 1:7024 FOUNTAIN OAK LN
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-5235
Mailing Address - Country:US
Mailing Address - Phone:618-410-9919
Mailing Address - Fax:
Practice Address - Street 1:961 N MARKET ST STOP 1
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1061
Practice Address - Country:US
Practice Address - Phone:618-939-4088
Practice Address - Fax:618-939-3419
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290045183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist