Healthcare Provider Details

I. General information

NPI: 1700172533
Provider Name (Legal Business Name): AZADEH KHOSHAKHLAGH PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 ALTAMONT AVE
SCHENECTADY NY
12303
US

IV. Provider business mailing address

17150 GALE AVE
CITY OF INDUSTRY CA
91745-1818
US

V. Phone/Fax

Practice location:
  • Phone: 518-355-2792
  • Fax:
Mailing address:
  • Phone: 626-854-1006
  • Fax: 518-207-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number053398
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number67420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: