Provider Demographics
NPI:1942881321
Name:SOUTHWORTH, AIDAN ROBERT (CPHT)
Entity type:Individual
Prefix:
First Name:AIDAN
Middle Name:ROBERT
Last Name:SOUTHWORTH
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 N FORBES RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-2013
Mailing Address - Country:US
Mailing Address - Phone:859-314-5044
Mailing Address - Fax:
Practice Address - Street 1:8333 ROCKSIDE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44125-6134
Practice Address - Country:US
Practice Address - Phone:216-369-2200
Practice Address - Fax:216-369-2201
Is Sole Proprietor?:No
Enumeration Date:2021-04-18
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT00354743183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician