Provider Demographics
NPI:1760667646
Name:GOHARI, KIAN
Entity Type:Individual
Prefix:
First Name:KIAN
Middle Name:
Last Name:GOHARI
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 1:50 N GREELEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAPPAQUA
Mailing Address - State:NY
Mailing Address - Zip Code:10514-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 N GREELEY AVE
Practice Address - Street 2:
Practice Address - City:CHAPPAQUA
Practice Address - State:NY
Practice Address - Zip Code:10514-3410
Practice Address - Country:US
Practice Address - Phone:914-238-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01588903Medicaid