Provider Demographics
NPI:1013123439
Name:O'DONNELL, DENNIS RAYMOND (RPH)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:RAYMOND
Last Name:O'DONNELL
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 1:15735 NICOLAI AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1664
Mailing Address - Country:US
Mailing Address - Phone:586-772-7109
Mailing Address - Fax:
Practice Address - Street 1:22835 VAN DYKE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089
Practice Address - Country:US
Practice Address - Phone:586-757-6505
Practice Address - Fax:586-757-7785
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist