Provider Demographics
NPI:1902185697
Name:AHLSTROM, LEE (RPH)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:AHLSTROM
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 1:6 ALTON PT
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1739
Mailing Address - Country:US
Mailing Address - Phone:410-208-1249
Mailing Address - Fax:
Practice Address - Street 1:11307 MANKLIN CREEK RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-208-3811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist