Provider Demographics
NPI:1104178060
Name:ALI, KHALED
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:ALI
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 1:20543 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2925
Mailing Address - Country:US
Mailing Address - Phone:718-749-5988
Mailing Address - Fax:
Practice Address - Street 1:20543 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2925
Practice Address - Country:US
Practice Address - Phone:718-749-5988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057464183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist