Provider Demographics
NPI:1033486089
Name:KHISTI, RAHUL TRYAMBAK
Entity Type:Individual
Prefix:
First Name:RAHUL
Middle Name:TRYAMBAK
Last Name:KHISTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 JUNCTION DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-2253
Mailing Address - Country:US
Mailing Address - Phone:804-752-2093
Mailing Address - Fax:804-798-8995
Practice Address - Street 1:133 JUNCTION DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-2253
Practice Address - Country:US
Practice Address - Phone:804-752-2093
Practice Address - Fax:804-798-8995
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT63697222OtherDRIVING LICENSE