Provider Demographics
NPI:1497360283
Name:SIDUN, ANDREA LYNN
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN
Last Name:SIDUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 AMBASSADOR DR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1996
Mailing Address - Country:US
Mailing Address - Phone:330-336-8990
Mailing Address - Fax:
Practice Address - Street 1:825 AMBASSADOR DR
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1996
Practice Address - Country:US
Practice Address - Phone:330-336-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03234156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist