Provider Demographics
NPI:1356673966
Name:IMAM, M.HASAN
Entity Type:Individual
Prefix:MR
First Name:M.HASAN
Middle Name:
Last Name:IMAM
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 1:81 INWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1519
Mailing Address - Country:US
Mailing Address - Phone:516-883-2857
Mailing Address - Fax:
Practice Address - Street 1:25709 UNION TPKE
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1250
Practice Address - Country:US
Practice Address - Phone:718-962-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist