Provider Demographics
NPI:1396409892
Name:ANSARI, AMBREEN (RPH)
Entity Type:Individual
Prefix:
First Name:AMBREEN
Middle Name:
Last Name:ANSARI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BROADVIEW VILLAGE SQ
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-4887
Mailing Address - Country:US
Mailing Address - Phone:708-731-5556
Mailing Address - Fax:
Practice Address - Street 1:800 BROADVIEW VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-4887
Practice Address - Country:US
Practice Address - Phone:708-731-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051304416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist