Provider Demographics
NPI:1962697615
Name:ODENWELLER, MELISSA MARIE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:ODENWELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-257-8614
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-8614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH03129455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program