Provider Demographics
NPI:1326478322
Name:ELIWA, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ELIWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 W BRIAR LAKE WAY APT 1A
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-8188
Mailing Address - Country:US
Mailing Address - Phone:414-204-4025
Mailing Address - Fax:
Practice Address - Street 1:2400 W BRIAR LAKE WAY APT 1A
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8188
Practice Address - Country:US
Practice Address - Phone:414-204-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17330-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist