Provider Demographics
NPI:1730892902
Name:KHALESSEH, DELARAM
Entity type:Individual
Prefix:
First Name:DELARAM
Middle Name:
Last Name:KHALESSEH
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 1:4200 BUCKINGHAM RD STE 105B
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76155-2618
Mailing Address - Country:US
Mailing Address - Phone:844-387-9090
Mailing Address - Fax:
Practice Address - Street 1:4200 BUCKINGHAM RD STE 105B
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76155-2618
Practice Address - Country:US
Practice Address - Phone:844-387-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV21029183500000X
CA62187183500000X
MD27869183500000X
VA0202219474183500000X
WVRP0012527183500000X
TX54209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist