Provider Demographics
NPI:1346525318
Name:AMBROSE, LEO L
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:L
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 WEST CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2477
Mailing Address - Country:US
Mailing Address - Phone:630-219-4170
Mailing Address - Fax:
Practice Address - Street 1:63 W 87TH ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565-2200
Practice Address - Country:US
Practice Address - Phone:630-778-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051026510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist