Provider Demographics
NPI:1689384976
Name:DEWALT, CONNOR AARON
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:AARON
Last Name:DEWALT
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 1:1310 DONALD AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2851
Mailing Address - Country:US
Mailing Address - Phone:440-226-1237
Mailing Address - Fax:
Practice Address - Street 1:1310 DONALD AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-2851
Practice Address - Country:US
Practice Address - Phone:440-226-1237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09216801183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician