Provider Demographics
NPI:1265167175
Name:JAYAKODY, ANURADHA
Entity type:Individual
Prefix:DR
First Name:ANURADHA
Middle Name:
Last Name:JAYAKODY
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 1:1259 AZIZ DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-5092
Mailing Address - Country:US
Mailing Address - Phone:734-846-7186
Mailing Address - Fax:
Practice Address - Street 1:120 S BUCKEYE ST
Practice Address - Street 2:
Practice Address - City:CROOKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43731-1015
Practice Address - Country:US
Practice Address - Phone:740-982-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03441984183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist