Provider Demographics
NPI:1922382340
Name:WAETJE, AMY ANN (PHARM D)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ANN
Last Name:WAETJE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 W HEATHER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2685
Mailing Address - Country:US
Mailing Address - Phone:208-598-5479
Mailing Address - Fax:
Practice Address - Street 1:700 12TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4255
Practice Address - Country:US
Practice Address - Phone:208-467-1560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist