Healthcare Provider Details

I. General information

NPI: 1821735002
Provider Name (Legal Business Name): ODA PRIMARY HEALTH CARE NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 WALLABOUT ST
BROOKLYN NY
11249-7830
US

IV. Provider business mailing address

74 WALLABOUT ST
BROOKLYN NY
11249-7830
US

V. Phone/Fax

Practice location:
  • Phone: 718-260-4600
  • Fax: 718-797-9075
Mailing address:
  • Phone: 718-260-4600
  • Fax: 718-797-9075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH DEUTSCH
Title or Position: CEO
Credential:
Phone: 718-260-4600