Provider Demographics
NPI:1639452196
Name:KHAN, FAROOQUE
Entity Type:Individual
Prefix:MR
First Name:FAROOQUE
Middle Name:
Last Name:KHAN
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 1:2040 ARMY TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-8975
Mailing Address - Country:US
Mailing Address - Phone:630-830-6558
Mailing Address - Fax:
Practice Address - Street 1:1111 W RUGELEY CT
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2154
Practice Address - Country:US
Practice Address - Phone:630-543-5894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.030707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist