Provider Demographics
NPI:1255875381
Name:ODEH, MAYSA
Entity type:Individual
Prefix:
First Name:MAYSA
Middle Name:
Last Name:ODEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 DUSTY MILLER LN
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307
Mailing Address - Country:US
Mailing Address - Phone:209-556-3932
Mailing Address - Fax:
Practice Address - Street 1:1628 DUSTY MILLER LN
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-9804
Practice Address - Country:US
Practice Address - Phone:209-556-3932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist