Provider Demographics
NPI:1801603766
Name:AL KHANSA, ROKAYA
Entity type:Individual
Prefix:
First Name:ROKAYA
Middle Name:
Last Name:AL KHANSA
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 1:27147 SIMONE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3339
Mailing Address - Country:US
Mailing Address - Phone:781-780-1757
Mailing Address - Fax:
Practice Address - Street 1:1015 S SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-5642
Practice Address - Country:US
Practice Address - Phone:989-839-2069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH1000146183500000X
MI5302415732183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist