Provider Demographics
NPI:1003428251
Name:AMBROSE, EVAN MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MICHAEL
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 W NORTHERN LIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-3340
Mailing Address - Country:US
Mailing Address - Phone:907-339-0560
Mailing Address - Fax:
Practice Address - Street 1:1650 W NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99517-3340
Practice Address - Country:US
Practice Address - Phone:907-339-0560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK163155183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist