Provider Demographics
NPI:1003075326
Name:KHALEELULLAH, AMTUL
Entity Type:Individual
Prefix:MRS
First Name:AMTUL
Middle Name:
Last Name:KHALEELULLAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 STUART RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3412
Mailing Address - Country:US
Mailing Address - Phone:516-561-1924
Mailing Address - Fax:
Practice Address - Street 1:20414 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2217
Practice Address - Country:US
Practice Address - Phone:718-464-4066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150310363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist