Provider Demographics
NPI:1104681519
Name:ODRISCOLL, EVAN JOHN (RPH)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:JOHN
Last Name:ODRISCOLL
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 1:1231 HAMILTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3222
Mailing Address - Country:US
Mailing Address - Phone:906-241-6960
Mailing Address - Fax:
Practice Address - Street 1:3610 PLAINFIELD AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-2402
Practice Address - Country:US
Practice Address - Phone:906-241-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302415842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist