Provider Demographics
NPI:1356028872
Name:KODUAH, LAWRENCE AKWASI
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:AKWASI
Last Name:KODUAH
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 1:2004 MORELAND BLVD UNIT 202
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1441
Mailing Address - Country:US
Mailing Address - Phone:331-250-8388
Mailing Address - Fax:
Practice Address - Street 1:1509 S NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6580
Practice Address - Country:US
Practice Address - Phone:217-351-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300952183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist