Basic Information
| Provider Information | |||||||||
| NPI: | 1114537727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FYNN | ||||||||
| FirstName: | AMBROSE | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 MEDICINE WAY RD | ||||||||
| Address2: | |||||||||
| City: | PERIDOT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284751400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 MEDICINE WAY RD | ||||||||
| Address2: | |||||||||
| City: | PERIDOT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284751400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2020 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S024612 | AZ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.