Provider Demographics
NPI:1851843247
Name:MARIAGNANAPRAKASAM, AMBUROSE (RPH)
Entity Type:Individual
Prefix:
First Name:AMBUROSE
Middle Name:
Last Name:MARIAGNANAPRAKASAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 GOLDFINCH DR
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918-8468
Mailing Address - Country:US
Mailing Address - Phone:304-673-3969
Mailing Address - Fax:
Practice Address - Street 1:1802 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3375
Practice Address - Country:US
Practice Address - Phone:304-252-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0008011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist