Provider Demographics
NPI:1437424892
Name:ISLAM, MOHAMMAD MAINUL
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:MAINUL
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 1:26203 E WILLISTON AVE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1146
Mailing Address - Country:US
Mailing Address - Phone:718-536-7424
Mailing Address - Fax:
Practice Address - Street 1:780 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3832
Practice Address - Country:US
Practice Address - Phone:203-353-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0011125183500000X
NYI055699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist