Provider Demographics
NPI:1720688690
Name:SIMONAVICE, CORY ALBERT (PHARMD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:ALBERT
Last Name:SIMONAVICE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6142 DRYDEN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45213-1739
Mailing Address - Country:US
Mailing Address - Phone:314-630-2883
Mailing Address - Fax:
Practice Address - Street 1:201 CHAMBER DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-2516
Practice Address - Country:US
Practice Address - Phone:513-248-4289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0211041835P0018X
OH0033344881835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist