Provider Demographics
NPI:1306446828
Name:KHAN, MARIAM NOUMAN
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:NOUMAN
Last Name:KHAN
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 1:8222 GUNSTON COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-5026
Mailing Address - Country:US
Mailing Address - Phone:571-533-4012
Mailing Address - Fax:
Practice Address - Street 1:4368 CHANTILLY SHOPPING CENTER DR
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-4016
Practice Address - Country:US
Practice Address - Phone:571-392-3087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202215487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist