Provider Demographics
NPI:1578842621
Name:D'AMBRA, THOMAS M (PHARM D)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:D'AMBRA
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 1:4 PINE EDGE PL
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8146
Mailing Address - Country:US
Mailing Address - Phone:631-424-8164
Mailing Address - Fax:
Practice Address - Street 1:4 PINE EDGE PL
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-8146
Practice Address - Country:US
Practice Address - Phone:631-424-8164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055694-1183500000X
NJ28RI03394200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist