Provider Demographics
NPI:1841577202
Name:CARBALLADA, CATHY
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:
Last Name:CARBALLADA
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 1:1285 SOM CENTER RD
Mailing Address - Street 2:T1324
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2073
Mailing Address - Country:US
Mailing Address - Phone:440-995-9919
Mailing Address - Fax:
Practice Address - Street 1:1285 SOM CENTER RD
Practice Address - Street 2:T1324
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2073
Practice Address - Country:US
Practice Address - Phone:440-995-9919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-12
Last Update Date:2011-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03118904183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist