Provider Demographics
NPI:1457330219
Name:ODOM, ELLIS R (RPH)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:R
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:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902
Mailing Address - Country:US
Mailing Address - Phone:573-686-2411
Mailing Address - Fax:573-686-8452
Practice Address - Street 1:686 LESTER ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5025
Practice Address - Country:US
Practice Address - Phone:573-686-2411
Practice Address - Fax:573-686-8452
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist