Provider Demographics
NPI:1487247888
Name:KHATIWODA, PREM
Entity type:Individual
Prefix:
First Name:PREM
Middle Name:
Last Name:KHATIWODA
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 1:1222 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2933
Mailing Address - Country:US
Mailing Address - Phone:814-384-8040
Mailing Address - Fax:
Practice Address - Street 1:1520 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-1302
Practice Address - Country:US
Practice Address - Phone:814-455-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP455413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist