Provider Demographics
NPI:1417122565
Name:ODOM, DAVID CARROLL (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CARROLL
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 1:5841 QUAIL MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-8542
Mailing Address - Country:US
Mailing Address - Phone:573-686-7238
Mailing Address - Fax:573-686-7239
Practice Address - Street 1:5841 QUAIL MEADOWS DR
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8542
Practice Address - Country:US
Practice Address - Phone:573-686-7238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO42049183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist