Provider Demographics
NPI:1679044556
Name:KHAN, EESHA
Entity Type:Individual
Prefix:
First Name:EESHA
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 ELDER LN
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1710 ROUTE 112
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-2229
Practice Address - Country:US
Practice Address - Phone:631-476-5360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist