Provider Demographics
NPI:1013651934
Name:PETERSON, AMANDA DIANE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:DIANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:DIANE
Other - Last Name:SADOFSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:207 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-2201
Mailing Address - Country:US
Mailing Address - Phone:918-838-2937
Mailing Address - Fax:
Practice Address - Street 1:207 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-2201
Practice Address - Country:US
Practice Address - Phone:918-838-2937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist