Basic Information
| Provider Information | |||||||||
| NPI: | 1598999153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'DONNELL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 559 VINCENT ST | ||||||||
| Address2: | 21 AMDS/SGSD - PHARMACY | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195561166 | ||||||||
| FaxNumber: | 8668677926 | ||||||||
| Practice Location | |||||||||
| Address1: | 559 VINCENT ST | ||||||||
| Address2: | 21 AMDS/SGSD - PHARMACY | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195561166 | ||||||||
| FaxNumber: | 8668677926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2009 | ||||||||
| LastUpdateDate: | 05/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 17022 | CO | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.