1750730099 NPI number — MR. JAHAN KEIVANJAH PHARMACIST

Table of content: MR. JAHAN KEIVANJAH PHARMACIST (NPI 1750730099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750730099 NPI number — MR. JAHAN KEIVANJAH PHARMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEIVANJAH
Provider First Name:
JAHAN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMACIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEIVANJAH
Provider Other First Name:
JAHN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMACIST
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1750730099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 N CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSHEN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10924-1550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-237-5557
Provider Business Mailing Address Fax Number:
845-237-5558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9000 LOCKHART GDN CTR
Provider Second Line Business Practice Location Address:
STORE # 13
Provider Business Practice Location Address City Name:
ST THOMAS
Provider Business Practice Location Address State Name:
VI
Provider Business Practice Location Address Postal Code:
00802-2685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
340-776-7098
Provider Business Practice Location Address Fax Number:
340-776-8030
Provider Enumeration Date:
06/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  145 , registered in the state of VI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 036527 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 06309219 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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