Provider Demographics
NPI:1952815201
Name:KODUA, THERESA (BS, PHARMD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:KODUA
Suffix:
Gender:F
Credentials:BS, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5255 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3702
Practice Address - Country:US
Practice Address - Phone:520-917-0130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-24
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022963183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist