Provider Demographics
NPI:1336750835
Name:ODUMAH, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ODUMAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 NE MERMAN DR APT M6
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-4572
Mailing Address - Country:US
Mailing Address - Phone:509-334-2981
Mailing Address - Fax:
Practice Address - Street 1:1690 SE HARVEST DR
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-6000
Practice Address - Country:US
Practice Address - Phone:781-971-7866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61018954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist