Provider Demographics
NPI:1851797930
Name:CODEMO, TODD (PHARMD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:CODEMO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 E SUNSHINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1144
Mailing Address - Country:US
Mailing Address - Phone:417-881-8841
Mailing Address - Fax:417-881-4627
Practice Address - Street 1:1302 E SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1144
Practice Address - Country:US
Practice Address - Phone:417-881-8841
Practice Address - Fax:417-881-4627
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014018661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014018661OtherPHARMACIST LICENSE