Provider Demographics
NPI:1821504507
Name:EROUK, ISLAM
Entity Type:Individual
Prefix:
First Name:ISLAM
Middle Name:
Last Name:EROUK
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 1:604 PENNSYLVANIA AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1639
Mailing Address - Country:US
Mailing Address - Phone:813-362-0168
Mailing Address - Fax:
Practice Address - Street 1:3026 HIGHWAY 144
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-0243
Practice Address - Country:US
Practice Address - Phone:270-684-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist