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General NPI Number Information
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NPI Number | 1487247888
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Entity Type | Individual
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Provider Name | PREM KHATIWODA
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Gender | Male
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Dates
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Enumeration Date | 02/16/2021
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Last Update Date | 02/16/2021
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Provider Practice Location Address
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Address Line | 1520 W 26TH ST
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City | ERIE
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State | PA
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Zip | 16508-1302
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Country | US
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Telephone | 814-455-9500
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Fax |
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Provider Business Mailing Address
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Address Line | 1222 MISSION DR
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City | ERIE
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State | PA
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Zip | 16509-2933
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Country | US
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Telephone | 814-384-8040
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RP455413
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License Number State | PA
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