Provider Demographics
NPI:1750730099
Name:KEIVANJAH, JAHAN (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:JAHAN
Middle Name:
Last Name:KEIVANJAH
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:MR
Other - First Name:JAHN
Other - Middle Name:
Other - Last Name:KEIVANJAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:6 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-1550
Mailing Address - Country:US
Mailing Address - Phone:845-237-5557
Mailing Address - Fax:845-237-5558
Practice Address - Street 1:9000 LOCKHART GDN CTR
Practice Address - Street 2:STORE # 13
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-2685
Practice Address - Country:US
Practice Address - Phone:340-776-7098
Practice Address - Fax:340-776-8030
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI145183500000X
NY036527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06309219Medicaid