Healthcare Provider Details

I. General information

NPI: 1801725676
Provider Name (Legal Business Name): CHARLES JOHN KANDRAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 SOM CENTER RD
WILLOUGHBY OH
44094-9646
US

IV. Provider business mailing address

5355 CHICKADEE LN
LYNDHURST OH
44124-2866
US

V. Phone/Fax

Practice location:
  • Phone: 440-946-7252
  • Fax: 440-946-0734
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03120824
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: