Provider Demographics
NPI:1891714796
Name:ODEGAARD, DOUGLAS MELVIN JR (RPH)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:MELVIN
Last Name:ODEGAARD
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
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Mailing Address - Street 1:730 LINDBERGH ST
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1134
Mailing Address - Country:US
Mailing Address - Phone:727-433-2472
Mailing Address - Fax:
Practice Address - Street 1:331 SIJAN AVE
Practice Address - Street 2:509 MDOS CC
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS382911835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy