MEDICARE: KODY EDWARD KAVANAUGH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26027721A	IN
2	183500000X	Pharmacist	03440067	OH

General Provider Information

NPI Number	:	1083250278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KODY EDWARD KAVANAUGH

Provider Business Mailing Address
First Line	:	22160 CENTER RIDGE RD
Second Line	:
City	:	ROCKY RIVER
State	:	OH
Zip	:	44116-3926
Country	:	US
Telephone Number	:	440-356-3287
Fax Number	:

Provider Business Practice Location Address
First Line	:	22160 CENTER RIDGE RD
Second Line	:
City	:	ROCKY RIVER
State	:	OH
Zip	:	44116-3926
Country	:	US
Telephone Number	:	440-356-3287
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2019
Last Update Date	:	10/26/2021

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Directions to “ KODY EDWARD KAVANAUGH ” Practice Location

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