Provider Demographics
NPI:1568622512
Name:ODUM, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:ODUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 BOWLES AVE
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2394
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2394
Practice Address - Country:US
Practice Address - Phone:636-496-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007010448183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist