Provider Demographics
NPI:1952473753
Name:MONA ODUSOLA
Entity Type:Organization
Organization Name:MONA ODUSOLA
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY PLAN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-993-6000
Mailing Address - Street 1:12121 RICHMOND AVE
Mailing Address - Street 2:SUITE 126
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-2432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12121 RICHMOND AVE
Practice Address - Street 2:SUITE 126
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-2432
Practice Address - Country:US
Practice Address - Phone:281-558-9433
Practice Address - Fax:281-558-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX198953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4572194OtherOTHER ID NUMBER
TX144930Medicaid