Healthcare Provider Details

I. General information

NPI: 1952473753
Provider Name (Legal Business Name): MONA ODUSOLA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12121 RICHMOND AVE SUITE 126
HOUSTON TX
77082-2432
US

IV. Provider business mailing address

12121 RICHMOND AVE SUITE 126
HOUSTON TX
77082-2432
US

V. Phone/Fax

Practice location:
  • Phone: 281-558-9433
  • Fax: 281-558-9017
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number19895
License Number StateTX

VIII. Authorized Official

Name: DENA FERMAN
Title or Position: THIRD PARTY PLAN COORDINATOR
Credential:
Phone: 314-993-6000