Provider Demographics
NPI:1508394016
Name:KWIATKOWSKI, ROSS
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:KWIATKOWSKI
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 1:4633 SUDER AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-1829
Mailing Address - Country:US
Mailing Address - Phone:419-727-2650
Mailing Address - Fax:
Practice Address - Street 1:4633 SUDER AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43611-1829
Practice Address - Country:US
Practice Address - Phone:419-727-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-28
Last Update Date:2017-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03227764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist