Provider Demographics
NPI:1538445457
Name:ODONOVAN, TRICIA RENAE (PHARMASCIST)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:RENAE
Last Name:ODONOVAN
Suffix:
Gender:F
Credentials:PHARMASCIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2052 352ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-8037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 GARFIELD ST N
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1765
Practice Address - Country:US
Practice Address - Phone:763-552-3103
Practice Address - Fax:763-552-3106
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117377183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist