MEDICARE: DR. ALICIA JO ODEAN PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	122460	MN

General Provider Information

NPI Number	:	1710362314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALICIA JO ODEAN PHARM.D.

Provider Business Mailing Address
First Line	:	10930 UNIVERSITY AVE NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-6120
Country	:	US
Telephone Number	:	763-755-6316
Fax Number	:

Provider Business Practice Location Address
First Line	:	10930 UNIVERSITY AVE NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-6120
Country	:	US
Telephone Number	:	763-755-6316
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2015
Last Update Date	:	12/23/2020

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