Provider Demographics
NPI:1851924757
Name:ODISH, WASIM
Entity Type:Individual
Prefix:
First Name:WASIM
Middle Name:
Last Name:ODISH
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 1:5039 VILLAGE SQUARE CIR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3383
Mailing Address - Country:US
Mailing Address - Phone:248-661-1934
Mailing Address - Fax:
Practice Address - Street 1:5529 SASHABAW RD
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3147
Practice Address - Country:US
Practice Address - Phone:248-620-6663
Practice Address - Fax:248-620-0236
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist