Provider Demographics
NPI:1609104892
Name:ODUMOSU, STEPHEN FOLORUNSO (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:FOLORUNSO
Last Name:ODUMOSU
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 1:8723 RIVER TRCE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-9549
Mailing Address - Country:US
Mailing Address - Phone:832-466-8646
Mailing Address - Fax:
Practice Address - Street 1:2710 NOGALITOS
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78225-1750
Practice Address - Country:US
Practice Address - Phone:210-533-7773
Practice Address - Fax:210-533-1870
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-26
Last Update Date:2009-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist