Provider Demographics
NPI:1528509668
Name:FARRELL, AMANDA LYNN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:FARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 CEDAR LAKE RD S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-2811
Mailing Address - Country:US
Mailing Address - Phone:507-327-0302
Mailing Address - Fax:
Practice Address - Street 1:6510 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-2811
Practice Address - Country:US
Practice Address - Phone:507-327-0302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN727643183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician