Provider Demographics
NPI:1467116897
Name:ODOM, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 S EVANSTON WAY APT 101
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-3858
Mailing Address - Country:US
Mailing Address - Phone:251-459-5237
Mailing Address - Fax:
Practice Address - Street 1:9395 CROWN CREST BLVD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-8573
Practice Address - Country:US
Practice Address - Phone:303-269-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHAT.0003847183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician