=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437424892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. MOHAMMAD MAINUL ISLAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2012
-----------------------------------------------------
Last Update Date | 03/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 780 E MAIN ST
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-353-9117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26203 E WILLISTON AVE
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-1146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-536-7424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0011125
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | I055699
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------