Provider Demographics
NPI:1457858151
Name:ISLAM, FAHAD (RPH)
Entity Type:Individual
Prefix:
First Name:FAHAD
Middle Name:
Last Name:ISLAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24459 PRESTON CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2747
Mailing Address - Country:US
Mailing Address - Phone:954-682-0003
Mailing Address - Fax:
Practice Address - Street 1:1183 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3231
Practice Address - Country:US
Practice Address - Phone:951-272-4427
Practice Address - Fax:951-272-1585
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA765823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA76582OtherCALIFORNIA BOARD OF PHARMACY