Provider Demographics
NPI:1306090980
Name:MGONJA, AMY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:MGONJA
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 1:8921 W HACKAMORE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1673
Mailing Address - Country:US
Mailing Address - Phone:208-994-4123
Mailing Address - Fax:800-431-6309
Practice Address - Street 1:8921 W HACKAMORE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1673
Practice Address - Country:US
Practice Address - Phone:208-994-4123
Practice Address - Fax:800-431-6309
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP58131835G0303X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric