Provider Demographics
NPI:1861911075
Name:ODURO, CHARLES (PHARMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ODURO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8203 BRIDGEWAY DR APT 2C
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46816-2344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9030 US HIGHWAY 24 W
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4752
Practice Address - Country:US
Practice Address - Phone:260-432-7413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027377A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist