Provider Demographics
NPI:1902151764
Name:KHATTAB, AMANDA I (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:I
Last Name:KHATTAB
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1197 AMBOY AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-2536
Mailing Address - Country:US
Mailing Address - Phone:732-549-3875
Mailing Address - Fax:
Practice Address - Street 1:1197 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2536
Practice Address - Country:US
Practice Address - Phone:732-549-3875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03494500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist