Provider Demographics
NPI:1588131379
Name:FUNDERBURG, AMANDA HUDGINS (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:HUDGINS
Last Name:FUNDERBURG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:GREY
Other - Last Name:HUDGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1209 S COLLEGE ST UNIT 2438
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4673
Mailing Address - Country:US
Mailing Address - Phone:704-589-0112
Mailing Address - Fax:
Practice Address - Street 1:2334 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5008
Practice Address - Country:US
Practice Address - Phone:704-523-8608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist