Healthcare Provider Details

I. General information

NPI: 1649924986
Provider Name (Legal Business Name): KHALED KOTB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 CUSTER PKWY
RICHARDSON TX
75080-1012
US

IV. Provider business mailing address

2644 CUSTER PKWY APT D
RICHARDSON TX
75080-1628
US

V. Phone/Fax

Practice location:
  • Phone: 972-470-1372
  • Fax:
Mailing address:
  • Phone: 347-702-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number69992
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: