Provider Demographics
NPI:1760096895
Name:BROCK, AMANDA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S SECOND ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3225
Mailing Address - Country:US
Mailing Address - Phone:662-728-5322
Mailing Address - Fax:662-728-3187
Practice Address - Street 1:100 S SECOND ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3225
Practice Address - Country:US
Practice Address - Phone:662-728-5322
Practice Address - Fax:662-728-3187
Is Sole Proprietor?:No
Enumeration Date:2020-09-05
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-16776183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist