Provider Demographics
NPI:1073518528
Name:ODOM, JOSEPH HAMILTON (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:HAMILTON
Last Name:ODOM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-3572
Mailing Address - Country:US
Mailing Address - Phone:843-687-2100
Mailing Address - Fax:843-493-3005
Practice Address - Street 1:1608 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3572
Practice Address - Country:US
Practice Address - Phone:843-248-4700
Practice Address - Fax:843-488-6346
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC717868Medicaid