Provider Demographics
NPI:1497036859
Name:ODOM, NICOLE E (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:E
Last Name:ODOM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 OLD POLK CITY RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-2314
Mailing Address - Country:US
Mailing Address - Phone:863-815-3373
Mailing Address - Fax:863-815-5303
Practice Address - Street 1:410 OLD POLK CITY RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-2314
Practice Address - Country:US
Practice Address - Phone:863-815-3373
Practice Address - Fax:863-815-5303
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist