Provider Demographics
NPI:1720745920
Name:BALES, AMANDA MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:BALES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1515 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9794
Mailing Address - Country:US
Mailing Address - Phone:262-334-9860
Mailing Address - Fax:262-334-4631
Practice Address - Street 1:1515 W PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9794
Practice Address - Country:US
Practice Address - Phone:262-334-9860
Practice Address - Fax:262-334-4631
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21101-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist