Provider Demographics
NPI:1518408327
Name:KHANDAKAR, SHAHED
Entity Type:Individual
Prefix:
First Name:SHAHED
Middle Name:
Last Name:KHANDAKAR
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 1:2648 FLOWER ST
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5604
Mailing Address - Country:US
Mailing Address - Phone:516-474-4504
Mailing Address - Fax:
Practice Address - Street 1:3800 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-2455
Practice Address - Country:US
Practice Address - Phone:718-239-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062671-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist