Healthcare Provider Details

I. General information

NPI: 1790072197
Provider Name (Legal Business Name): MARYAM N KHAN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 SHAW AVE
CLOVIS CA
93612-3928
US

IV. Provider business mailing address

1155 SHAW AVENUE SIERRA PAVILION RITE AID 1155 SHAW AVE
CLOVIS CA
93612
US

V. Phone/Fax

Practice location:
  • Phone: 559-297-4198
  • Fax: 559-297-7388
Mailing address:
  • Phone: 559-297-4198
  • Fax: 559-297-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH 54359
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: