Provider Demographics
NPI:1922619873
Name:KHODEIR, MAGED A (RPH)
Entity Type:Individual
Prefix:
First Name:MAGED
Middle Name:A
Last Name:KHODEIR
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11339 SW RESTON CT
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2787
Mailing Address - Country:US
Mailing Address - Phone:772-475-4702
Mailing Address - Fax:
Practice Address - Street 1:2901 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3222
Practice Address - Country:US
Practice Address - Phone:772-336-3108
Practice Address - Fax:772-336-8765
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS53982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist