Provider Demographics
NPI:1720442163
Name:ODELL, MICHAEL WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:ODELL
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 1:1801 NW US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34428-6133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 NW US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6133
Practice Address - Country:US
Practice Address - Phone:352-563-5995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS28857OtherPHARMACY LICENSE