Provider Demographics
NPI:1558643767
Name:KHASIDOVA, ILONA (PHARM D)
Entity Type:Individual
Prefix:
First Name:ILONA
Middle Name:
Last Name:KHASIDOVA
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TRUMBULL ST APT 2607
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06103-1526
Mailing Address - Country:US
Mailing Address - Phone:646-267-6933
Mailing Address - Fax:
Practice Address - Street 1:323 CROMWELL AVE
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1801
Practice Address - Country:US
Practice Address - Phone:860-563-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056234183500000X
CT0015174183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist