Provider Demographics
NPI:1013431014
Name:BHUIYAN, SHAH ALAM
Entity Type:Individual
Prefix:
First Name:SHAH
Middle Name:ALAM
Last Name:BHUIYAN
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 1:3815 TIMBERCREST DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-6813
Mailing Address - Country:US
Mailing Address - Phone:248-740-1582
Mailing Address - Fax:
Practice Address - Street 1:24831 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-3390
Practice Address - Country:US
Practice Address - Phone:586-486-5037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020371913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy