Healthcare Provider Details

I. General information

NPI: 1013123439
Provider Name (Legal Business Name): DENNIS RAYMOND O'DONNELL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22835 VAN DYKE
WARREN MI
48089
US

IV. Provider business mailing address

15735 NICOLAI AVE
EASTPOINTE MI
48021-1664
US

V. Phone/Fax

Practice location:
  • Phone: 586-757-6505
  • Fax: 586-757-7785
Mailing address:
  • Phone: 586-772-7109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302024050
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: