Provider Demographics
NPI:1740565225
Name:BISHARA, IMAN
Entity Type:Individual
Prefix:
First Name:IMAN
Middle Name:
Last Name:BISHARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ANCHORAGE ROAD, APT 2
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050
Mailing Address - Country:US
Mailing Address - Phone:516-987-6472
Mailing Address - Fax:
Practice Address - Street 1:1 ANCHORAGE RD APT 2
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3103
Practice Address - Country:US
Practice Address - Phone:516-987-6472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist