Provider Demographics
NPI:1003360322
Name:IBRAHIM, JAD
Entity Type:Individual
Prefix:
First Name:JAD
Middle Name:
Last Name:IBRAHIM
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 1:3413 S HOPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5624
Mailing Address - Country:US
Mailing Address - Phone:321-446-5460
Mailing Address - Fax:
Practice Address - Street 1:3413 S HOPKINS AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5624
Practice Address - Country:US
Practice Address - Phone:321-446-5460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist