Provider Demographics
NPI:1972161479
Name:MODD, LATANYA LYNN
Entity type:Individual
Prefix:
First Name:LATANYA
Middle Name:LYNN
Last Name:MODD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-2749
Mailing Address - Country:US
Mailing Address - Phone:567-251-3900
Mailing Address - Fax:
Practice Address - Street 1:2017 BROAD AVE
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-2749
Practice Address - Country:US
Practice Address - Phone:567-251-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7274OtherCOMMERCIAL
OH7274Medicaid