Provider Demographics
NPI:1487254835
Name:OMAR, HAYTHAM
Entity type:Individual
Prefix:
First Name:HAYTHAM
Middle Name:
Last Name:OMAR
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 1:180 N KING ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-1120
Mailing Address - Country:US
Mailing Address - Phone:413-587-9555
Mailing Address - Fax:413-587-0303
Practice Address - Street 1:180 N KING ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-1120
Practice Address - Country:US
Practice Address - Phone:413-587-9555
Practice Address - Fax:413-587-0303
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH27592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist