Provider Demographics
NPI:1235565599
Name:OGANOV, AMBARTSUM MARTIN (PHARM D)
Entity Type:Individual
Prefix:
First Name:AMBARTSUM
Middle Name:MARTIN
Last Name:OGANOV
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1718
Mailing Address - Country:US
Mailing Address - Phone:509-765-1217
Mailing Address - Fax:509-765-4410
Practice Address - Street 1:200 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1718
Practice Address - Country:US
Practice Address - Phone:509-765-1217
Practice Address - Fax:509-765-4410
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60368859183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist