Provider Demographics
NPI:1992578348
Name:ISLAM, SHAMSUL X
Entity type:Individual
Prefix:
First Name:SHAMSUL
Middle Name:X
Last Name:ISLAM
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 1:234 E 149TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5504
Mailing Address - Country:US
Mailing Address - Phone:718-579-5659
Mailing Address - Fax:
Practice Address - Street 1:355 I U WILLETS RD
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2811
Practice Address - Country:US
Practice Address - Phone:646-675-5530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist