Provider Demographics
NPI:1285039867
Name:FORNWALT, ROY BENJAMIN II (PHARMD,RPH)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:BENJAMIN
Last Name:FORNWALT
Suffix:II
Gender:M
Credentials:PHARMD,RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20405 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5324
Mailing Address - Country:US
Mailing Address - Phone:216-752-4866
Mailing Address - Fax:
Practice Address - Street 1:20405 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5324
Practice Address - Country:US
Practice Address - Phone:216-752-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-25
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03132257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist