Provider Demographics
NPI:1679373450
Name:PRAK, DEJALEDA
Entity type:Individual
Prefix:
First Name:DEJALEDA
Middle Name:
Last Name:PRAK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 VANDALIA AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3908
Mailing Address - Country:US
Mailing Address - Phone:401-403-1669
Mailing Address - Fax:
Practice Address - Street 1:25524 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4048
Practice Address - Country:US
Practice Address - Phone:440-892-0525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03445155183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist