Provider Demographics
NPI:1861650723
Name:IMAM, NAYYAR U (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:NAYYAR
Middle Name:U
Last Name:IMAM
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-4130
Mailing Address - Country:US
Mailing Address - Phone:631-698-7788
Mailing Address - Fax:631-698-0103
Practice Address - Street 1:3663 ROUTE 112
Practice Address - Street 2:STE 1
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4130
Practice Address - Country:US
Practice Address - Phone:631-698-7788
Practice Address - Fax:631-698-0103
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037149183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01742121Medicaid
NY1262840001Medicare NSC