=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659791432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENA MODI-PANDEJEE PHARM D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2014
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 S 108TH ST
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-1926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-545-0385
-----------------------------------------------------
Fax | 414-203-4323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12338 W COLD SPRING RD
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53228-2439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-571-9071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH027036
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 19693-40
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------