MEDICARE: ELNAZ KHADEM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	77696	CA

General Provider Information

NPI Number	:	1356820138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELNAZ KHADEM

Provider Business Mailing Address
First Line	:	5170 MOORPARK AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95129-2139
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5170 MOORPARK AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95129-2139
Country	:	US
Telephone Number	:	408-257-9918
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2018
Last Update Date	:	08/12/2018

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Directions to “ ELNAZ KHADEM ” Practice Location

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