Provider Demographics
NPI:1164708137
Name:KHAN, MMUDASSIR ALI (MPHARM)
Entity Type:Individual
Prefix:
First Name:MMUDASSIR
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:MPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 BUCHANAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4129
Mailing Address - Country:US
Mailing Address - Phone:718-982-7724
Mailing Address - Fax:
Practice Address - Street 1:557 BUCHANAN AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4129
Practice Address - Country:US
Practice Address - Phone:718-982-7724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031745-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist