Provider Demographics
NPI:1104205244
Name:IBRAHIM, MINA BOSHRA GHATTAS
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:BOSHRA GHATTAS
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 1:10623 PANGBORN AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-2939
Mailing Address - Country:US
Mailing Address - Phone:562-522-4686
Mailing Address - Fax:
Practice Address - Street 1:4633 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1803
Practice Address - Country:US
Practice Address - Phone:323-666-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist