Provider Demographics
NPI:1093181687
Name:AMBROSE, DUSTIN J (PHARMD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:J
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 1:121 BRYANT RD
Mailing Address - Street 2:
Mailing Address - City:TURNER
Mailing Address - State:ME
Mailing Address - Zip Code:04282-3932
Mailing Address - Country:US
Mailing Address - Phone:814-572-9348
Mailing Address - Fax:
Practice Address - Street 1:150 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7241
Practice Address - Country:US
Practice Address - Phone:207-623-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR45441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist