Provider Demographics
NPI:1770185894
Name:IBERAHME, AMENATE
Entity Type:Individual
Prefix:
First Name:AMENATE
Middle Name:
Last Name:IBERAHME
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 1:102 SHEPHERDSON LN NE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4532
Mailing Address - Country:US
Mailing Address - Phone:404-957-3309
Mailing Address - Fax:
Practice Address - Street 1:13059 FAIR LAKES PARKWAY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033
Practice Address - Country:US
Practice Address - Phone:703-631-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202213514183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202213514OtherDEPARTMENT OF HEALTH PROFESSIONS (BOARD OF PHARMACY)