Provider Demographics
NPI:1184946089
Name:THEISZ, WILLIAM MARTIN (RP)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:MARTIN
Last Name:THEISZ
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:191 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-3319
Mailing Address - Country:US
Mailing Address - Phone:201-666-8047
Mailing Address - Fax:973-473-8387
Practice Address - Street 1:105 TERHUNE AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-2805
Practice Address - Country:US
Practice Address - Phone:973-473-2243
Practice Address - Fax:973-473-8387
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28R101400000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist