Provider Demographics
NPI:1073387262
Name:KUDIOR, ELLIS
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:KUDIOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 E AURORA RD
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-2729
Mailing Address - Country:US
Mailing Address - Phone:330-468-4800
Mailing Address - Fax:
Practice Address - Street 1:663 E AURORA RD
Practice Address - Street 2:
Practice Address - City:MACEDONIA
Practice Address - State:OH
Practice Address - Zip Code:44056-2729
Practice Address - Country:US
Practice Address - Phone:330-468-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03443821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist