Provider Demographics
NPI:1326244583
Name:IMAM, MOHAMMED MASUDUL (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:MASUDUL
Last Name:IMAM
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6697 RIVERMILL CLUB DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7428
Mailing Address - Country:US
Mailing Address - Phone:561-495-3628
Mailing Address - Fax:561-495-3430
Practice Address - Street 1:5352 LINTON BLVD
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6514
Practice Address - Country:US
Practice Address - Phone:561-495-3628
Practice Address - Fax:561-495-3430
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist