Provider Demographics
NPI:1396756359
Name:DECKER, AMANDA SUE (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SUE
Last Name:DECKER
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 1:180 MEADOWBROOK
Mailing Address - Street 2:
Mailing Address - City:WALNUT SHADE
Mailing Address - State:MO
Mailing Address - Zip Code:65771-9332
Mailing Address - Country:US
Mailing Address - Phone:417-294-4085
Mailing Address - Fax:
Practice Address - Street 1:1102 N MASSEY BLVD
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7607
Practice Address - Country:US
Practice Address - Phone:417-724-0798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09323183500000X
MO2001023388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2001023388OtherMO LISC
MO35914908Medicaid
ARPD09323OtherAR LISC