Provider Demographics
NPI:1861703225
Name:ODIAKOSA, ETHEL (PHARMD)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:ODIAKOSA
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 1:255 N EL CIELO RD
Mailing Address - Street 2:SUITE C322
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-6992
Mailing Address - Country:US
Mailing Address - Phone:760-969-6560
Mailing Address - Fax:760-328-2230
Practice Address - Street 1:255 N EL CIELO RD
Practice Address - Street 2:SUITE C322
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-6992
Practice Address - Country:US
Practice Address - Phone:760-969-6560
Practice Address - Fax:760-328-2230
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA61675OtherSTATE LICENSE