Provider Demographics
NPI:1427711902
Name:BODNOVICH, KERRY II
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:BODNOVICH
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25105 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-3782
Mailing Address - Country:US
Mailing Address - Phone:216-409-3320
Mailing Address - Fax:
Practice Address - Street 1:25105 CEDAR RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-3782
Practice Address - Country:US
Practice Address - Phone:216-409-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03232980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist