Provider Demographics
NPI:1740508951
Name:KHAIMOV, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:KHAIMOV
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 1:361 E FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5053
Mailing Address - Country:US
Mailing Address - Phone:212-792-4040
Mailing Address - Fax:212-792-4042
Practice Address - Street 1:361 E FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5053
Practice Address - Country:US
Practice Address - Phone:212-792-4040
Practice Address - Fax:212-792-4042
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044768183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist