Provider Demographics
NPI:1508464538
Name:ODEDRA, HARISH R
Entity Type:Individual
Prefix:
First Name:HARISH
Middle Name:R
Last Name:ODEDRA
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 1:2809 OLIVE HWY STE 160
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-6133
Mailing Address - Country:US
Mailing Address - Phone:530-588-1325
Mailing Address - Fax:
Practice Address - Street 1:130 TURNBERRY RD
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-2271
Practice Address - Country:US
Practice Address - Phone:530-588-1325
Practice Address - Fax:530-660-4551
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist