Provider Demographics
NPI:1194343178
Name:KHODOR, KHALIL
Entity type:Individual
Prefix:
First Name:KHALIL
Middle Name:
Last Name:KHODOR
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 1:7243 FENTON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1748
Mailing Address - Country:US
Mailing Address - Phone:313-888-1361
Mailing Address - Fax:
Practice Address - Street 1:33740 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-6404
Practice Address - Country:US
Practice Address - Phone:158-669-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302048529183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist