Healthcare Provider Details

I. General information

NPI: 1487164448
Provider Name (Legal Business Name): EVELYN OBAWOYE AMBUSH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5270 PEACHTREE PKWY STE 114A
PEACHTREE CORNERS GA
30092-2508
US

IV. Provider business mailing address

PO BOX 930355
NORCROSS GA
30003-0355
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-9089
  • Fax:
Mailing address:
  • Phone: 678-428-2897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number029494
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: