Provider Demographics
NPI:1043661804
Name:IBRAHIM, AHMED YOSRY
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:YOSRY
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 1:169 OVERMOUNT AVE
Mailing Address - Street 2:APT B
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-3232
Mailing Address - Country:US
Mailing Address - Phone:201-655-8461
Mailing Address - Fax:
Practice Address - Street 1:100 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3266
Practice Address - Country:US
Practice Address - Phone:973-661-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03561100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist