Healthcare Provider Details

I. General information

NPI: 1427575257
Provider Name (Legal Business Name): MUDASAR KHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2271 RICHMOND AVE
STATEN ISLAND NY
10314-3903
US

IV. Provider business mailing address

73 CARNEGIE AVE
STATEN ISLAND NY
10314-3819
US

V. Phone/Fax

Practice location:
  • Phone: 718-698-0500
  • Fax:
Mailing address:
  • Phone: 347-831-8240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number063267
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: