Healthcare Provider Details

I. General information

NPI: 1871008292
Provider Name (Legal Business Name): CHARLES ODONALD PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 E MAIN STREET
EDMORE MI
48829-9755
US

IV. Provider business mailing address

3149 N GRAND AVE
PIERSON MI
49339-9408
US

V. Phone/Fax

Practice location:
  • Phone: 989-427-5275
  • Fax:
Mailing address:
  • Phone: 616-799-0068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302023181
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: