Provider Demographics
NPI:1790072197
Name:KHAN, MARYAM N (RPH)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:N
Last Name:KHAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 SHAW AVENUE SIERRA PAVILION
Mailing Address - Street 2:RITE AID 1155 SHAW AVE
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612
Mailing Address - Country:US
Mailing Address - Phone:559-297-4198
Mailing Address - Fax:559-297-7388
Practice Address - Street 1:1155 SHAW AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3928
Practice Address - Country:US
Practice Address - Phone:559-297-4198
Practice Address - Fax:559-297-7388
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 54359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist