Provider Demographics
NPI:1720311319
Name:WILLIS, KHIANA KEREN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KHIANA
Middle Name:KEREN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25711 LYNDON
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-3340
Mailing Address - Country:US
Mailing Address - Phone:313-587-5755
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:DETROIT VAMC OUTPATIENT PHARMACY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19394183500000X
MI53020401021835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist