Healthcare Provider Details

I. General information

NPI: 1649637265
Provider Name (Legal Business Name): GREGORY AMBROSE PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3558 RUFFIN RD SUITE 101
SAN DIEGO CA
92123-2596
US

IV. Provider business mailing address

3558 RUFFIN RD SUITE 101
SAN DIEGO CA
92123-2596
US

V. Phone/Fax

Practice location:
  • Phone: 858-627-5644
  • Fax: 858-636-2236
Mailing address:
  • Phone: 858-627-5644
  • Fax: 858-636-2236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number42991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: