Provider Demographics
NPI:1093067902
Name:MANSOUR, HESHAM NABIL IBRAHIM (RPH)
Entity Type:Individual
Prefix:MR
First Name:HESHAM
Middle Name:NABIL IBRAHIM
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E 3RD ST APT 5A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-7647
Mailing Address - Country:US
Mailing Address - Phone:443-889-7870
Mailing Address - Fax:
Practice Address - Street 1:18616 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11366-1734
Practice Address - Country:US
Practice Address - Phone:718-264-0319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist