Provider Demographics
NPI:1609217652
Name:AMIN, KHODAYAR
Entity Type:Individual
Prefix:
First Name:KHODAYAR
Middle Name:
Last Name:AMIN
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 1:17600 SW 63RD MNR
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST RANCHES
Mailing Address - State:FL
Mailing Address - Zip Code:33331-1735
Mailing Address - Country:US
Mailing Address - Phone:954-434-6162
Mailing Address - Fax:
Practice Address - Street 1:17600 SW 63RD MNR
Practice Address - Street 2:
Practice Address - City:SOUTHWEST RANCHES
Practice Address - State:FL
Practice Address - Zip Code:33331-1735
Practice Address - Country:US
Practice Address - Phone:954-434-6162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-07
Last Update Date:2013-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29557183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist