Provider Demographics
NPI:1669757753
Name:MADERICH, AMANDA (PHARMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MADERICH
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 1:2015 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2015 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2538
Practice Address - Country:US
Practice Address - Phone:715-392-9550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120052183500000X
WI16172-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist