Provider Demographics
NPI:1992313431
Name:TICKNOR, CHRIS
Entity type:Individual
Prefix:MR
First Name:CHRIS
Middle Name:
Last Name:TICKNOR
Suffix:
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 1:9000 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:937-734-5838
Mailing Address - Fax:
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-734-5838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-20809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist