Provider Demographics
NPI:1568909398
Name:IBRAHIM, DEMIANA
Entity Type:Individual
Prefix:
First Name:DEMIANA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 NORTH LN
Mailing Address - Street 2:APT #B10
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1226
Mailing Address - Country:US
Mailing Address - Phone:347-636-6520
Mailing Address - Fax:
Practice Address - Street 1:77-105 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5985
Practice Address - Country:US
Practice Address - Phone:973-259-9290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03845400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist