Healthcare Provider Details

I. General information

NPI: 1508114588
Provider Name (Legal Business Name): CARLOTTA CHAYA HENRIQUEZ-SMITH RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2012
Last Update Date: 08/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 CLARK AVE
CLEVELAND OH
44109-1136
US

IV. Provider business mailing address

3402 CLARK AVE
CLEVELAND OH
44109-1136
US

V. Phone/Fax

Practice location:
  • Phone: 216-961-9414
  • Fax: 216-651-8205
Mailing address:
  • Phone: 216-961-9414
  • Fax: 216-651-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03132091
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: