Provider Demographics
NPI:1215789177
Name:ISSA, MARIAM (PHARMD)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:ISSA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E SANDFORD BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-4750
Mailing Address - Country:US
Mailing Address - Phone:914-530-3001
Mailing Address - Fax:
Practice Address - Street 1:500 E SANDFORD BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-4750
Practice Address - Country:US
Practice Address - Phone:914-530-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0679671835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology