Provider Demographics
NPI:1497778906
Name:MALMEN, AMY L (RPH)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:MALMEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 COUNTRY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-7637
Mailing Address - Country:US
Mailing Address - Phone:217-348-7047
Mailing Address - Fax:
Practice Address - Street 1:600 LINCOLN AVE
Practice Address - Street 2:1102 HUMAN SERVICES
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-3011
Practice Address - Country:US
Practice Address - Phone:217-581-7779
Practice Address - Fax:217-581-7780
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist