Provider Demographics
NPI:1417669706
Name:ISLAM, MOHAMMAD MONIRUL
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:MONIRUL
Last Name:ISLAM
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 1:1688 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-3010
Mailing Address - Country:US
Mailing Address - Phone:718-842-2217
Mailing Address - Fax:
Practice Address - Street 1:1688 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-3010
Practice Address - Country:US
Practice Address - Phone:718-842-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI069674183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist