Provider Demographics
NPI:1982394904
Name:IMAM, MUHAMMED ISIAKU
Entity Type:Individual
Prefix:
First Name:MUHAMMED
Middle Name:ISIAKU
Last Name:IMAM
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 1:2024 LAKE VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CHULUOTA
Mailing Address - State:FL
Mailing Address - Zip Code:32766-9145
Mailing Address - Country:US
Mailing Address - Phone:204-617-7712
Mailing Address - Fax:
Practice Address - Street 1:1235 N 14TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3822
Practice Address - Country:US
Practice Address - Phone:352-787-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist