Provider Demographics
NPI:1679143234
Name:AMPUERO, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:AMPUERO
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 1:3520 GARDEN MIST CIR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30011-2375
Mailing Address - Country:US
Mailing Address - Phone:404-553-3373
Mailing Address - Fax:
Practice Address - Street 1:7300 S RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-6162
Practice Address - Country:US
Practice Address - Phone:404-553-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist