Provider Demographics
NPI:1235350794
Name:SPIVACK, MYRNA ELAINE (RPH)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:ELAINE
Last Name:SPIVACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MYRNA
Other - Middle Name:ELAINE
Other - Last Name:PENDERY-SPIVACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6410 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-1253
Mailing Address - Country:US
Mailing Address - Phone:216-883-0183
Mailing Address - Fax:
Practice Address - Street 1:6410 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-1253
Practice Address - Country:US
Practice Address - Phone:216-883-0183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-18213183500000X
MI5302023660183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist