Provider Demographics
NPI:1952345159
Name:ODON PHARMACY LLC
Entity Type:Organization
Organization Name:ODON PHARMACY LLC
Other - Org Name:ODON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-636-4600
Mailing Address - Street 1:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:ODON
Mailing Address - State:IN
Mailing Address - Zip Code:47562-0355
Mailing Address - Country:US
Mailing Address - Phone:812-636-4600
Mailing Address - Fax:812-636-8004
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ODON
Practice Address - State:IN
Practice Address - Zip Code:47562-1218
Practice Address - Country:US
Practice Address - Phone:812-636-4600
Practice Address - Fax:812-636-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
IN60003675A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100294700AMedicaid
2026659OtherPK
IN100294700AMedicaid