Healthcare Provider Details

I. General information

NPI: 1235565599
Provider Name (Legal Business Name): AMBARTSUM MARTIN OGANOV PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E BROADWAY AVE
MOSES LAKE WA
98837-1718
US

IV. Provider business mailing address

200 E BROADWAY AVE
MOSES LAKE WA
98837-1718
US

V. Phone/Fax

Practice location:
  • Phone: 509-765-1217
  • Fax: 509-765-4410
Mailing address:
  • Phone: 509-765-1217
  • Fax: 509-765-4410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60368859
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: