Provider Demographics
NPI:1043975295
Name:ODEESH, MORIN
Entity type:Individual
Prefix:
First Name:MORIN
Middle Name:
Last Name:ODEESH
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 1:16 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2819
Mailing Address - Country:US
Mailing Address - Phone:630-832-7821
Mailing Address - Fax:630-832-3195
Practice Address - Street 1:16 E LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2819
Practice Address - Country:US
Practice Address - Phone:630-832-7821
Practice Address - Fax:630-832-3195
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051304365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist