Provider Demographics
NPI:1083986699
Name:KORNOKOVICH, KIMBERLY (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KORNOKOVICH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7796 MUNSON RD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-3745
Mailing Address - Country:US
Mailing Address - Phone:440-257-6258
Mailing Address - Fax:440-209-9096
Practice Address - Street 1:7796 MUNSON RD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-3745
Practice Address - Country:US
Practice Address - Phone:440-257-6258
Practice Address - Fax:440-209-9096
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03319685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist