Provider Demographics
NPI:1669894614
Name:KHAITOV, ALEKSANDR
Entity type:Individual
Prefix:
First Name:ALEKSANDR
Middle Name:
Last Name:KHAITOV
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 1:393 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-4026
Mailing Address - Country:US
Mailing Address - Phone:516-489-2211
Mailing Address - Fax:
Practice Address - Street 1:10005 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-898-1100
Practice Address - Fax:718-898-1101
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY058812OtherNEW YORK BOARD OF PHARMACY