Provider Demographics
NPI:1295023943
Name:IBRAHIM, MARY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 SAN FELIPE ST
Mailing Address - Street 2:T-0955
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-3406
Mailing Address - Country:US
Mailing Address - Phone:713-331-0166
Mailing Address - Fax:713-331-0166
Practice Address - Street 1:4323 SAN FELIPE ST
Practice Address - Street 2:T-0955
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-3406
Practice Address - Country:US
Practice Address - Phone:713-331-0166
Practice Address - Fax:713-331-0166
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47555OtherLICENSE NUMBER