Provider Demographics
NPI:1902345374
Name:KHAN, FAISAL
Entity Type:Individual
Prefix:
First Name:FAISAL
Middle Name:
Last Name:KHAN
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 1:7780 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-3109
Mailing Address - Country:US
Mailing Address - Phone:331-318-7905
Mailing Address - Fax:
Practice Address - Street 1:224 N BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2386
Practice Address - Country:US
Practice Address - Phone:331-318-7905
Practice Address - Fax:888-626-5899
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-18
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist