Provider Demographics
NPI:1588993745
Name:AMBROSE, JAY MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:MICHAEL
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:MICHAEL
Other - Last Name:AMBROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:317 E CHICKASAW RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6229
Mailing Address - Country:US
Mailing Address - Phone:757-871-4181
Mailing Address - Fax:
Practice Address - Street 1:317 E CHICKASAW RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6229
Practice Address - Country:US
Practice Address - Phone:757-871-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02020074491835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric