Provider Demographics
NPI:1154779247
Name:EBROM, JONATHAN (PHARMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:EBROM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3487
Mailing Address - Country:US
Mailing Address - Phone:760-452-3522
Mailing Address - Fax:619-268-8158
Practice Address - Street 1:1450 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3487
Practice Address - Country:US
Practice Address - Phone:760-452-3522
Practice Address - Fax:619-268-8158
Is Sole Proprietor?:No
Enumeration Date:2016-05-30
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist