Provider Demographics
NPI:1881169993
Name:ODEH, HEITHEM
Entity type:Individual
Prefix:
First Name:HEITHEM
Middle Name:
Last Name:ODEH
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 1:244 PATERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-3123
Mailing Address - Country:US
Mailing Address - Phone:201-450-7300
Mailing Address - Fax:
Practice Address - Street 1:2 BERGEN TPKE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07660-2340
Practice Address - Country:US
Practice Address - Phone:908-241-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03974300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist