Provider Demographics
NPI:1942881321
Name:SOUTHWORTH, AIDAN ROBERT (CPHT)
Entity Type:Individual
Prefix:
First Name:AIDAN
Middle Name:ROBERT
Last Name:SOUTHWORTH
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-1841
Mailing Address - Country:US
Mailing Address - Phone:859-397-0439
Mailing Address - Fax:
Practice Address - Street 1:3735 PALOMAR CENTRE DR STE 80
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1168
Practice Address - Country:US
Practice Address - Phone:859-223-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-18
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT00354743183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician