Provider Demographics
NPI:1497358477
Name:IBRAHIM, KEROLOS (RPH)
Entity Type:Individual
Prefix:
First Name:KEROLOS
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:OSPREY
Mailing Address - State:FL
Mailing Address - Zip Code:34229-9692
Mailing Address - Country:US
Mailing Address - Phone:941-966-5667
Mailing Address - Fax:
Practice Address - Street 1:1220 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:OSPREY
Practice Address - State:FL
Practice Address - Zip Code:34229
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI59545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist