Healthcare Provider Details

I. General information

NPI: 1063898807
Provider Name (Legal Business Name): IJEOMA LORRAINE ODIGWE PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80B VETERANS BLVD
PUEBLO OF ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 278
SAN FIDEL NM
87049-0278
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5812
  • Fax: 505-552-5464
Mailing address:
  • Phone: 301-752-9505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202213884
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: