Healthcare Provider Details

I. General information

NPI: 1144824079
Provider Name (Legal Business Name): ETHAN MICHAEL ODINEAL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2020
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7909 HIGHWAY N
DARDENNE PRAIRIE MO
63368-7382
US

IV. Provider business mailing address

7909 HIGHWAY N
DARDENNE PRAIRIE MO
63368-7382
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-8450
  • Fax: 636-561-8450
Mailing address:
  • Phone: 636-561-8450
  • Fax: 636-561-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number43211
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.304733
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26029005A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2022011896
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: