Provider Demographics
NPI:1780843672
Name:EBRAHIM, ADEL A
Entity Type:Individual
Prefix:
First Name:ADEL
Middle Name:A
Last Name:EBRAHIM
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 1:1914 FRANKFORD AVE UNIT 131
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3008
Mailing Address - Country:US
Mailing Address - Phone:850-215-6617
Mailing Address - Fax:
Practice Address - Street 1:301 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-6124
Practice Address - Country:US
Practice Address - Phone:850-522-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist