Provider Demographics
NPI:1124666326
Name:KHAN, MASOOMA R (RPH)
Entity type:Individual
Prefix:
First Name:MASOOMA
Middle Name:R
Last Name:KHAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 PROPP AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-3513
Mailing Address - Country:US
Mailing Address - Phone:857-264-6457
Mailing Address - Fax:
Practice Address - Street 1:22 DEPOT HILL RD
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2258
Practice Address - Country:US
Practice Address - Phone:203-262-1831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0014680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist