Provider Demographics
NPI:1295015584
Name:ODUKOGBE, COLLINS O (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:COLLINS
Middle Name:O
Last Name:ODUKOGBE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 SEATON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-9246
Mailing Address - Country:US
Mailing Address - Phone:803-467-9172
Mailing Address - Fax:803-807-9111
Practice Address - Street 1:431 MEADOWLARK ST
Practice Address - Street 2:
Practice Address - City:SHAW A F B
Practice Address - State:SC
Practice Address - Zip Code:29152-5019
Practice Address - Country:US
Practice Address - Phone:803-895-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC124421835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC12442OtherSTATE
PARP443290OtherSTATE
NC20070OtherSTATE LICENSE