Provider Demographics
NPI:1770953929
Name:VANTAGGI, KIA (RPH)
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:VANTAGGI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10502 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-1955
Mailing Address - Country:US
Mailing Address - Phone:216-451-9027
Mailing Address - Fax:
Practice Address - Street 1:8001 W 130TH ST
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-1001
Practice Address - Country:US
Practice Address - Phone:440-845-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.021314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist