Healthcare Provider Details

I. General information

NPI: 1265714752
Provider Name (Legal Business Name): FRED ODELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5917 HIGH ST W
PORTSMOUTH VA
23703-4505
US

IV. Provider business mailing address

5917 HIGH ST W
PORTSMOUTH VA
23703-4505
US

V. Phone/Fax

Practice location:
  • Phone: 757-686-5929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202005268
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: