Provider Demographics
NPI:1548931066
Name:IVORY, MARC QUINN
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:QUINN
Last Name:IVORY
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 1:4401 MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3670
Mailing Address - Country:US
Mailing Address - Phone:216-297-2001
Mailing Address - Fax:216-297-2003
Practice Address - Street 1:4401 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3670
Practice Address - Country:US
Practice Address - Phone:216-297-2001
Practice Address - Fax:216-297-2003
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist