Provider Demographics
NPI:1083250278
Name:KAVANAUGH, KODY EDWARD
Entity Type:Individual
Prefix:
First Name:KODY
Middle Name:EDWARD
Last Name:KAVANAUGH
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 1:22160 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-3926
Mailing Address - Country:US
Mailing Address - Phone:440-356-3287
Mailing Address - Fax:
Practice Address - Street 1:22160 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-3926
Practice Address - Country:US
Practice Address - Phone:440-356-3287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027721A183500000X
OH03440067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist