Provider Demographics
NPI:1275952871
Name:WAMBOLDT, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WAMBOLDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:ALAN
Other - Last Name:WAMBOLDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:14015 N 94TH ST APT 3060
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3738
Mailing Address - Country:US
Mailing Address - Phone:480-323-9961
Mailing Address - Fax:
Practice Address - Street 1:14015 N 94TH ST APT 3060
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3738
Practice Address - Country:US
Practice Address - Phone:480-323-9961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS013400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist