Provider Demographics
NPI:1467794628
Name:IBRAHIM, MOSTAFA A
Entity Type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:A
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 1:8 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-1565
Mailing Address - Country:US
Mailing Address - Phone:715-823-2222
Mailing Address - Fax:715-823-6000
Practice Address - Street 1:8 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1565
Practice Address - Country:US
Practice Address - Phone:715-823-2222
Practice Address - Fax:715-823-6000
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16281-40183500000X
NJ28RI03410700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist