Provider Demographics
NPI:1922384189
Name:KHALAF, KHOLOUD
Entity Type:Individual
Prefix:
First Name:KHOLOUD
Middle Name:
Last Name:KHALAF
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 1:3208 14TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-3036
Mailing Address - Country:US
Mailing Address - Phone:262-308-1106
Mailing Address - Fax:
Practice Address - Street 1:1810 30TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1437
Practice Address - Country:US
Practice Address - Phone:262-551-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14694-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist