Provider Demographics
NPI:1063898807
Name:ODIGWE, IJEOMA LORRAINE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:IJEOMA
Middle Name:LORRAINE
Last Name:ODIGWE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0278
Mailing Address - Country:US
Mailing Address - Phone:301-752-9505
Mailing Address - Fax:
Practice Address - Street 1:80B VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO OF ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5812
Practice Address - Fax:505-552-5464
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202213884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist