Provider Demographics
NPI:1407106792
Name:ODICHO, EDWARD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:ODICHO
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 1:2842 W SUMMERDALE AVE APT 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3424
Mailing Address - Country:US
Mailing Address - Phone:773-934-3132
Mailing Address - Fax:
Practice Address - Street 1:2842 W SUMMERDALE AVE APT 2W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3424
Practice Address - Country:US
Practice Address - Phone:773-934-3132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist