Healthcare Provider Details

I. General information

NPI: 1295015584
Provider Name (Legal Business Name): COLLINS O ODUKOGBE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 MEADOWLARK ST
SHAW A F B SC
29152-5019
US

IV. Provider business mailing address

164 SEATON RIDGE DR
BLYTHEWOOD SC
29016-9246
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-2273
  • Fax:
Mailing address:
  • Phone: 803-467-9172
  • Fax: 803-807-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number12442
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: