Provider Demographics
NPI:1861776437
Name:RAUEN, AMANDA L
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:L
Last Name:RAUEN
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 1:502 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:AVISTON
Mailing Address - State:IL
Mailing Address - Zip Code:62216-3446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:704 CAMBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1964
Practice Address - Country:US
Practice Address - Phone:618-632-6920
Practice Address - Fax:618-632-7228
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist